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11 March 2020
Preventing chronic disease is key in reducing lifestyle related diseases such as overweight and obesity and Type 2 diabetes. It's well documented that lifestyle changes such as being physically active and eating healthy foods can have a positive impact on an individual's health and wellbeing. GPs play a key role in assisting and supporting their patients to make these changes & access relevant complementary services.
This webinar walks you through the stages of behaviour change, helps you assess a patients readiness for change and factors that impact individuals ability to make sustainable changes to their lifestyle. We also discuss health coaching principles when communicating with patients to support them to actively manage their lifestyle related to chronic disease risk.
Dr Jeannie Yoo
Sammi: Good evening everybody and welcome to this evening’s Applying health coaching principles when communicating with patients at risk of chronic disease webinar. My name is Samantha and I am your host for this evening. Before we start, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present. Sammi: Good evening everybody and welcome to this evening’s Applying health coaching principles when communicating with patients at risk of chronic disease webinar. My name is Samantha and I am your host for this evening. Before we start, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.
So I would like to introduce our presenters for this evening, Dr Jeannie Yoo and Sarah Koh. Jeannie is a Sydney-based GP and Clinical Director of Remedy Healthcare, a national provider of health coaching and in-home health services. Jeannie has a background in medical education and quality improvement, digital innovation and medical ethics. She graduated from the University of Sydney and has practised in Sydney and Melbourne. Thanks for joining us, Jeannie.
Jeannie: My pleasure.
Sammi: And we also have Sarah. Sarah is a Senior Project Officer for the Get Healthy Service at the New South Wales Office of Preventative Health. She has an Honours in Nutrition and Dietetics, Bachelor of Exercise and Sports Science, Certificate 4 in Training and Assessment and is a qualified health coach. Her experience spans across public health, the food industry, research and private practice, but her special interest lies in coaching and behaviour change. Sarah currently supports the State-wide expansion of the Get Healthy Service into new clinical fields which we will be hearing more about later. So, thank you Sarah for joining us.
Sarah: Thank you.
Sammi: Wonderful. I will hand over to Jeannie now to take us through the learning outcomes for this evening and we will then proceed with the rest of the presentation.
Jeannie: Thanks very much, Sammi. So tonight we have got a series of learning outcomes as you can see on the screen. We are aiming to increase our GP participants’ awareness of where health coaching fits on the continuum of care. To identify the most appropriate stages when a GP can refer a patient for health coaching, discuss the benefits of health coaching in improving a patient’s health and to describe how to refer patients to existing New South Wales health services, such as the Get Healthy Service.
Sarah: So I am sure everybody online is very aware that Australia has unacceptably high rates of risk factors for chronic disease. As a population, we are sitting more and moving less. Our diet is becoming increasingly energy dense but nutrient poor, and these factors are leading to the rising rates of obesity and preventable diseases like diabetes, cardiovascular diseases and certain cancers within our population.
So while there are many factors that contribute to chronic disease, some of which are beyond our control like our family history, our culture, our age, the one we would really like to focus on today is the unhealthy behaviours. We know that for our patients, this is one of the most common risk factors and is a main cause of chronic disease. However, it is also something that as GPs we can influence and help change. And I think the important thing to note here is that small changes make a really big difference. So we know that for every kilogram of weight lost, the risk of developing type 2 diabetes reduces by 16%, and for people with pre-diabetes, losing just 5% or 10% of their body weight can actually prevent that progression on to diabetes in six out of 10 people.
Jeannie: Thanks very much, Sarah. So, changing behaviour is important but we also know that it is complex and there are a range of barriers to that, so we would like to invite our GPs tonight to send in their responses about which barriers their patients most commonly site as a reason why they cannot change various lifestyle behaviours. Thanks very much, Sammi. So in the meantime while we are waiting for those results to come in, Sarah, would you be able to explain how health coaching can support patients to overcome barriers to changing their lifestyle?
Sarah: Thanks, Jeannie. It is a really good question and I think one of the common misconceptions when it comes to working with a health coach is that the health coach is actually going to solve those barriers for the patient, but that is not actually what happens. So, part of coaching is recognising that the person themselves are the expert in their own world and it is really important that they come up with the solutions to their barriers. And by doing so, often that gives them that sense of ownership, and they are much more likely to then actually implement those strategies as well. So, an example I like to give here is I know in the past I worked with someone who really struggled to eat regularly throughout the day, and her biggest barrier was remembering to do so, because she was just so busy at work that she was not having regular meals. She would get to the end of the day with all intentions to choose healthy options but was just ravenous and would then grab anything and everything. And so we talked about how she could overcome this barrier and I think automatically as health professionals, we can think of a number of different solutions that she could be trying, but following that coaching principle rather than giving her options, we asked her, well what could you do instead to remind yourself to eat more regularly. And she actually came up with the idea that because she works at a computer, she would actually change the password of her computer to be mindful, and that was her prompt. So that every time she got up and left the computer, she had to type that in and it reminded her of her goals and to really be mindful to eat more regularly throughout the day. And that was I think a really unique solution that as health professionals we would not be able to come up with and it is really important, and highlights the importance of giving participants or patients that ownership of their goals. And working with a coach can really help to normalise that these barriers are all a part of that change process.
Jeannie: So that is a great example Sarah, and one which really illustrates the fact that the participant is an expert and that solutions that they come up with are likely to be the most effective, rather than ones that we as health professionals think would be a good idea. So certainly time, being stressed and being unsuccessful in the past, along with cost are all common barriers that our patients provide or bring up as reasons why they are unable to change their behaviours.
So, I want to then move to sort of the next aspect of health coaching which is that as we know as GPs, information in itself is important but on its own is not effective in encouraging positive behaviour change. So Sarah, what are some of the other important elements when we are thinking about whether someone is ready to engage in the health coaching process?
Sarah: Thanks, Jeannie. It is a really good question and I think information is definitely key. But as health professionals and GPs, as you would know, it is not the only element that is important for behaviour change. So I would like to introduce a principle that you may or may not be familiar with that is called RICK. And this is a coaching principle that stands for readiness, importance, confidence and knowledge and it follows the concept that for someone to be able to effectively change their behaviour, as health professionals, it is important that we gauge where they are at in these four domains. So, firstly they might know what they need to do, but right now are they actually ready to make changes? Have they got so much going on in their life that they are not able to prioritise let us say eating more healthily at the moment? So, how ready they are.
The second is the importance, and this is really linked to I guess, how much they value their health and where their motivations are. So for example you might have someone who let us say, is about to start a new medication for diabetes but tells you that their mum has had diabetes for their whole life and it has not affected them at all, so it is really not an issue and they are not concerned. And so by discussing the level of importance, it gives you a little bit of an indication in terms of whether or not they value or understand the impact that lifestyle change might have on their health and health risk.
The next is confidence. So I think somebody’s belief in themselves to be able to change definitely has an influence on their ability to then succeed in that change. So if you hear someone say, oh I will never be able to lose weight or I have tried 100 times in the past and I always fail, that kind of language really indicates that low confidence and it is something that we can work with to help them be more confident, set more appropriate and realistic goals. A
And then finally knowledge. So as GPs you are a very good source of evidence-based information for your patients that you see, and it is important that they understand why or what they need to do to be able to address those health risks.
Jeannie: So thanks very much, Sarah. I think that is really a great way to remember that it is not just what you know, but all of those other elements that are important ingredients in behaviour change. We have had a question come in which is saying that what patients need is the real will to change. So I think that it might be helpful to go through the model of the stages of change that we as GPs have certainly heard of and which is a really underpinning principle behind health coaching.
Sarah: Yes, sure. And I guess leading on from what we have just talked about, that RICK scale can really give you a little bit of indication to where someone is in terms of the stages of change. So just to briefly refresh everyone, there are the five stages of change. So, pre-contemplation where someone is not even thinking about change. Contemplation, where on one hand they can see the benefits of say, getting a little bit more active, but on the other hand there are all these other things that are stopping them from actually starting right now. Preparation, where they might be actively taking steps to start, but have not started yet. So for example they could have joined the gym, they might be starting to plan their meals for the week. Action, where they are actively implementing some strategies to work towards that goal and maintenance where they have been able to maintain that change for a little while. They have been able to overcome some of those barriers and really build up that confidence to keep going.
Jeannie: And so perhaps one of the major helpful aspects of this model is that we can think about where patients are up to in the stages of change and also to be realistic about where we are trying to move them to. So I understand from a health coaching perspective, we are not expecting to go from the very beginning to the very end right in one go. You actually try to move a patient to the next stage of change.
Sarah: That is exactly right, Jeannie. So for somebody who is contemplative, so thinking about getting more active, you are not going to get them to start walking tomorrow, but what you would be wanting to do is help them move to that next stage which is preparation, so getting them thinking about, well what would be the benefit if you did start? And what would be the things you would need to do if you decided to start? And that is true for all of the stages. Your goal is to move to that next stage of change.
Jeannie: So, relapse is also an important feature of the model, and of course that is an almost universal experience for anyone who is trying to change an ingrained behaviour. When can relapse occur, and how does health coaching support patients when they do relapse?
Sarah: Yes, that is a really good question. So, I think it is important to note that relapse can occur at any of the stages of change and can cause somebody to jump back into any stage of change. So if you do hear that your patient has relapsed, it is important to reassess where they are again, because it is not an assumption that they automatically got back to where they left off. And where coaching can really support is to help normalise that relapse is a part of that change cycle. And it really is learning from those previous experiences what happened, what got them off track and what they can do to get back on track. So it is like for example, getting the person to think about developing this new habit like the skill of riding a bike. So just because you have fallen off does not mean that you have failed. And if you think that way, you probably will not ever get back on that bike again. But it is recognising what happened, what got in the way, and how can we overcome that in future?
Jeannie: Thanks very much for that, Sarah. I think we might go on there to talk about what health coaching is overall. And so in summary, it is a practice in which trained health professionals apply evidence based principles and techniques informed by health psychology and coaching psychology to assist their patients to achieve positive health and lifestyle outcomes, attitude and behaviour change. Where does health coaching fit overall in the continuum of care for a patient?
Sarah: So, I think where health coaching fits in best is really supporting patients to implement the changes that they are wanting to see with their lifestyle. So if you think about it, you know GPs provide really valuable advice to their patients, they see their patients in follow up, but they might not have the time or the capacity to really help patients to come up with the specific goals to explore motivators and to really make those changes. And so where coaching can really come in is to compliment the care that GPs offer, by supporting patients to really understand why these changes are important to them and what their real motivators are. Set specific goals, identify barriers, come up with your own solutions and really give patients back accountability so that in between their GP appointments they are able to make progress in these lifestyle areas. That can really have an impact on clinical outcomes.
Jeannie: So health coaching really is very much a compliment to the work that GPs are trying to do with their patients?
Jeannie: Okay, so let us go on. So in terms of the elements that you have referred to so far, so health coaches help their patients or clients set realistic and long term goals, identify key motivators, help their clients or patients decide on a SMART goal or practical action steps. Identify likely barriers, decide on effective solutions and collaboration with their patient. Assess their confidence and set a plan for follow up. So we might go on to look at how this works in practice through a case study.
Okay so this case study is of a 48-year-old woman who has obesity. In her past medical history she has been noted to have impaired fasting glucose, hypercholesterolaemia and suffers from depression and anxiety for which she is on an SSRI. She is someone with a lot of demands in her life, so she has three children, a full time office job. She needs to travel two hours a day and has a lot of financial pressures. And her GP has noted that her height is 161 cm, weight 85 kg which makes her BMI 32.8, so in the obesity range and she has a waist circumference of 106 cm. And she confesses that she has had multiple unsuccessful attempts at losing weight and particularly at maintaining weight loss. She agrees that her current lifestyle could be better. She has sort of no structured exercise and limited incidental activity and she would like to improve her diet and to lose weight. So, from a GP perspective, this is certainly a patient that would need to lose a significant amount of weight and losing weight is essential for reducing her risk of diabetes and her overall cardiovascular risk. She sounds like someone we should be referring for health coaching, but what else would you want to know before deciding whether to refer this patient at this particular point in time?
Sarah: Yes, so thinking back to that RICK principle that we introduced is a really good point. So, speaking to her about some of those four domains like is she ready to change? Does she feel like for example weight loss is something that is important to her at this point in time given the demands that she has with her job, her kids and such? Does she feel confident that she would be able to lose weight if she wanted to work towards that? And often opening the conversation using some of those domains from RICK can be a really good leading question to how coaching can actually support her, and is a nice way to set up that conversation for a referral.
Jeannie: So in this case, the patient is referred and we are now going to go through a role play of how a coaching interaction might sound. So we have Carly here with us who is one of our senior health coaches, so Sarah and Karly.
Sarah: Thank you. So we are going to do a bit of a role play of what a coaching call on the Get Healthy Service would sound like, which we will talk about a little bit more. Karly is going to play the role of my patient with the case history that Jeannie has just gone through, and I am going to play the role of the health coach in this instance.
So, Karly you have told me that you have been referred to the service to lose 20 kg that your GP has advised you to do, to really help with your health at the moment. Tell me how confident you are feeling that you can actually achieve that?
Karly: Not confident at all if I am honest. I actually left home feeling a little bit flat. I do not even know where to start.
Sarah: And it is really normal. It can feel very overwhelming when you think about having to lose that amount of weight. Sometimes setting a goal that is slightly smaller and that you feel is a little bit more realistic can be a good place to start. And we can always progress that goal as you make some progress. How does that sound to you?
Karly: Yes, that actually sounds a lot more achievable.
Sarah: So I guess Karly, if you think about a small goal that you would like to begin with, something that would be more achievable for you. Have you got something in mind?
Karly: Do you think 5 kg could be a good place to start?
Sarah: Yes, I think that is a really good idea. Sometimes breaking it down a little bit can be helpful. And I guess weight is the result of the actions and changes within our lifestyle. So, if you think about maybe not over-focussing on the weight, but how your lifestyle is at the moment, is there something that you would like to see be different?
Karly: I think, well right now I do not think I really have the time to exercise. Definitely my eating could do with some improving. I know I probably just eat too much over the day really, particularly at dinner time.
Sarah: Yes, and is that something that is important for you to work on right now to improve, you mentioned particularly your eating?
Karly: Yes, definitely.
Sarah: And tell me why that is important to you?
Karly: Well I know, well I know when I have eaten healthily in the past and I have lost weight, I have been a lot more energetic so I think if I were to lose weight, if I were to eat healthier, I would be able to keep up with my kids, I would probably be feeling a bit more energetic at work and be a litte more confident in myself as well.
Sarah: And what would that mean for you, if you had more of that confidence and more of that energy?
Karly: Oh, it would mean I would be a better mum, a better worker. It would mean a lot.
Sarah: Okay, so it does sound like this is something that is really important to you. If you like perhaps, I know you have mentioned there are a few areas you wanted to work on with both your exercise and your food, but perhaps we can maybe chose one area to begin with and just make some smaller changes there. I can really hear that is important for you to set those examples for the long term and I really do not want you to feel overwhelmed with changing too much at once. So is it that dinner meal that you think you are wanting to work on, or is there a different priority that you would like to start with?
Karly: No, I definitely think the dinner meal would be a good place to start. And I think that is a bit easier for me to start with as well. I do not have much time, really.
Sarah: Okay, so tell me a little bit about what is happening for you with dinner at the moment?
Karly: Well to be honest my meals are really healthy. I know how to eat healthily. I have done Weight Watchers. I have done it all, it is just that I eat too much. So my husband serves me up my dinner and he just puts too much on my plate, so I think that is the main issue there.
Sarah: Okay, so it sounds like it is the portion sizes that you are wanting to address, is that right?
Karly: Yes, so I know that, you know I follow the guidelines, I have lots of veggies, I have that lean protein. I get brown rice and things like that. But I am just really eating too much of it.
Sarah: Okay, so tell me, what is it that you have in mind that you would like to see change with your portion sizes?
Karly: I reckon maybe if I just cut it back by half, or maybe just not have the carbs on my plate?
Sarah: Okay, and is that something you have tried in the past?
Sarah: Tell me a little bit about how that has gone for you?
Karly: It was terrible. I was so hungry.
Sarah: And look, sometimes when we do make big changes like that, it can be really hard to sustain. Can I give you a little bit of a suggestion?
Karly: Yes please.
Sarah: There is a bit of a rule that says if you reduce your portions by about say 10 or 20%, it is just enough for us to notice a little bit of a difference and to help with that weight loss, but not too much of a difference that leads you feeling hungry and looking for something else later in that evening for instance. And it also means that you are not then cutting out a whole food group like the carbohydrates which still provide really valuable nutrients. What do you think about that, Karly?
Karly: Okay. That sounds a bit more achievable, I think.
Sarah: Okay, and is that something you feel like you would like to try to do?
Karly: Yes, I think so.
Sarah: So if you were to reduce your potion sizes at dinner, what steps would you need to put in place to be able to actually do that?
Karly: I think I would definitely need to have a good chat with my husband to tell him to stop putting so much food on my plate. I think that would be the first thing to do.
Sarah: Okay, and when would you like to have that conversation?Sarah: Okay, and when would you like to have that conversation?
Karly: Oh, I can do that today.
Sarah: Okay, great. Is there anything else you would need to do?
Karly: I think another part of the problem is actually I am always going back for seconds.
Karly: So I think what I need to do is actually not have leftovers, or just pop them in the fridge straight after I portion them out, so that way I am not tempted.
Sarah: That is a great idea. And how might you remind yourself to do that?
Karly: Well I have actually have a picture of a potion plate. I can actually just stick that on the fridge and that can remind both my husband and me that that is sort of what I am aiming for.
Sarah: That is fabulous. So, Karly can you think of anything that might actually get in the way or might stop you from being able to do that?
Karly: I am just a bit worried that I might still feel hungry. I am so used to eating larger portions at night.
Sarah: Yes and look it is really common and it is good that you are acknowledging that. In terms of hunger are you aware how long it normally takes I guess for your brain to register that feeling of satiety or feeling full?
Karly: No, I did not realise.
Sarah: So it normally takes about say 20 minutes, and so sometimes what can happen is if we eat very quickly, we might still think that we are not full, but we have not actually given ourselves to really register. So often taking that time to eat a little more mindfully or slowing it down can actually really give your body that little bit of an opportunity to be more in tune and really understand whether or not you still are hungry before you decide if you would like to have more servings.
Karly: That makes a lot of sense.
Sarah: What are your thoughts on that, Karly?
Karly: Yes, I can try that out.
Sarah: Okay, and so in terms of speaking to your husband, popping up that reminder and putting in place some of these strategies, how confident do you feel that you would be able to do that?
Karly: I am actually feeling pretty confident after this chat. I would say maybe a 9 out of 10.
Sarah: Right, that is really confident. So, how would it work with you if perhaps I gave you a call back in say another two weeks’ time and we can follow up with how you are going with your portion sizes and then reassess and take the next steps from there?
Karly: Yes, that sounds great.
Jeannie: Thank you so much, Sarah and Karly. Look I am sure my GP colleagues would agree that there is nothing like listening to an actual coaching interaction to understand how that works, and some of the things that really strike me are the kind of detail that the coach goes into with the patient and the way that the solutions and the goals are patient-led. So when the patient does not know what to do, I mean there is guidance and suggestions from the coach, but it is really very much a patient-led process. And very few of us GPs would have the time or let us say the patience to be able to go into that level of detail, and yet that level of detail is what is needed in order to support significant behaviour change.
Jeannie: Look, what we might do is, we will go to the second half of the case study and after that, we might respond to some of the questions that have come through. So I think that some of our GPs are certainly finding the strategies that are being illustrated here are strategies that they would like to implement in their own practices. But before we get to that, let us finish the other half of the case study. So, when Karly comes back for her next call, she reports that she has had some success with reducing portions with all of the sort of detailed strategy that she developed with Sarah and she has actually lost 1.2 kg. However she is still a bit disheartened. She left the last call with a confidence of 9 out of 10, but she has found it a struggle to overcome a pattern of emotional eating. She has tried to address this, with little success in the past. So she has got that insight that this is an issue for her, and she has identified that stress is what her trigger is to eat emotionally and she gets on well with her GP but she feels a bit embarrassed and she does not really want to discuss the stress with her GP, but it is something that she would like to speak to her health coach about. So, let us return to the role play.
Sarah: So we are just going to kick off following up from that next coaching call.
So Karly, when we last spoke we set a bit of a plan to reduce your portion sizes, particularly for your dinner meal. Tell me, how did you go with that?
Karly: Oh it was so good. My husband was really supportive and I have actually already lost 1.2 kg.
Sarah: That is fantastic. And it is great to see that you have had that progress at such an early stage. Have you noticed any differences in terms of how you are feeling overall?
Karly: Yes, like I do feel good. I am very impressed I guess that I have been able to make that change, but at the same time, I know I can still be doing better. I am still binge eating which I feel really I guess a bit disheartened that that is still going on for me.
Sarah: Okay, so the first thing I would just like to say is that it is really great to see that you have recognised the success and the progress that you have made in just two weeks since we last spoke. That is a really positive thing. But I can still hear that there are areas that you would like to work on, particularly you mentioned that binge eating. So is that something that you would like for us to discuss a little bit more today?
Karly: Yes. I actually think I am ready to be talking about that a bit more.
Sarah: Okay, and I am more than happy to support you with that. It is something that is really common that people do experience and it is often that we find ourselves eating for reasons not necessarily linked to hunger. If you take a moment to reflect on I guess, what might be the triggers that might cause you to overeat or to binge eat, what do feel like those are for you, Karly?
Karly: Oh it is definitely stress. Work has been so stressful lately. I even sort of look forward to coming home and having that time to have my chocolate and my cakes and things like that. So it is definitely stress related.
Sarah: And tell me, how are you managing your stress at the moment?
Karly: Oh, terribly. Not at all.
Sarah: Okay. And so I guess it is really important if we understand that it is stress, that we have strategies in place to support us and good networks as well to support us so that we are not allowing it to have too much of an impact on our lives. And tell me, if you were wanting to get extra support, where would you go to get some extra support for your stress, Karly?
Karly: Um, well it is not something I have brought up with my doctor just yet. I did go to my manager actually the other day and spoke a little but about it. I have not done anything so far.
Sarah: Okay, and is it something you would feel comfortable speaking to your doctor about?
Karly: No. I do not think I could. I normally go to the doctor and we talk about my health, or usually my weight is the common topic, but I do not know, I have never felt comfortable talking about the stress.
Sarah: Okay, and you mentioned you also spoke to your manager about it at work. Tell me a bit about that.
Karly: Well, so I brought it up the other day and she actually did mention a counselling program we have at work and I actually I have not thought too much about it until this conversation.
Sarah: Sure. And a lot of workplaces often offer programs like the employee assistance program which can link you in with a psychologist or a counsellor and often that can be helpful, particularly if you are dealing with work-related stress. Is that something that you would be open to explore further, Karly?
Karly: Yes, actually I think I actually will. I think it has gotten to that point where I realise I need to do something about my stress levels.
Sarah: Okay, well perhaps if you like I can follow up with you on our next call to see how that has gone.
Karly: Yes, that sounds good.
Sarah: Okay, and so going back to what you mentioned about that binge eating, we can definitely talk about some different strategies to support you to manage that moving forward. Tell me, has there been anything that you have done in the past to try and address that?
Karly: Yes, I very unsuccessfully told myself that I will not eat that chocolate. But I still do, so I have not been very successful with it.
Sarah: And it is a really common thing and it is a really challenging thing. And you mentioned before that you really looked forward to it. And it is one of those things where food not only nourishes us, but it brings us a lot of joy. And that is not a bad thing. But I guess it is when we are over-consuming that we realise the impact it then has on other areas of our life and our health. So, perhaps if you like I can share with you some different strategies that you might find that work for you to help address this.
Karly: Yes please.
Sarah: So there is an approach that is called the four D’s. Have you heard of that before?
Karly: No, I cannot say I have.
Sarah: Have you got a pen and paper with you, Karly?
Karly: Yes, I do.
Sarah: Okay so I will talk you through it and perhaps you can see if this is something that might work for you in your life. So the four D’s is an acronym and it stands for Delaying, Distract, Deep Breathing or Drinking water, and the last one is a little bit funny, it is De-catastrophize.
So I will explain to you what that means. So the first one is Delay, and that means it is the concept of taking some time. So if you feel like you have a craving and you know that it is not related to hunger, sometimes those cravings can feel like the urge is very strong, but it also tends to wax and wane and can often fade away. So taking that time to delay and ask yourself or maybe give yourself that 15 or 20 minutes to see if you still really would like that treat or if you would like to consider how much you would want if you actually still felt like it, is a nice strategy to just allow you to think about that food or that situation a little bit more mindfully.
The second one is Distract. So you mentioned that often it is stress and you know, food is that enjoyment and that relief at the end of the day that can help bring you that joy after a stressful work day. So it is thinking about, well what else could you do to distract yourself but to also bring you that, I guess stress relief that you are looking for. So if there is anything else that you could do in your time that would be enjoyable. Things that you might not normally have the time or think to do.
The third thing, Deep Breathing or Drinking water, and that is around bringing some mindfulness to your body and taking some deep breaths, recognising and challenging whether it is true hunger or whether it is a craving at that time.
And then finally, De-catastrophize. And that is really acknowledging the fact that change is hard, and you know, often we might have the right intentions and we might have all these strategies and it might only work some of the time and other times things might be too stressful and it might not go the way you planned, but that is okay, and it is recognising that that is a normal part of the change process. And if you do find yourself slipping up, not to be too hard on yourself. You have not failed and it is about focussing on what you could do next time to really overcome some of those challenges you might have experienced.
Do any of those strategies resonate with you? Is there anything that you feel might work?
Karly: All of them, but I think particularly the Distract one. So there are definitely so many other things I could be doing at night time instead of eating. So actually what I think I need to do is come up with a list of what these things could be. So that way I could go to that instead of going to food.
Sarah: Okay, and just thinking about it now, is there anything that is coming to mind that you might do instead that could bring you that joy or that stress relief?
Karly: So definitely firstly just doing something with the kids. Having a game that they like to play and I can be involved with that. Or even having like having a bubble bath or something. I never take that time to myself.
Sarah: To yourself.
Karly: Yes. So I am sure there are other things I can add to the list, but they are just a couple that I can think of now.
Sarah: That is fantastic that you have already got those ideas, and it sounds like they are definitely things that would help to relieve some of that stress and bring joy to your day. And look, it is hard if you are used to that routine of coming back and having something unhealthy or using food as that source of joy. It is hard to sometimes remember these other strategies. Is there anything that you could be doing to remind or prompt yourself?
Karly: I actually do not know. Do you have any ideas?
Sarah: Yes I can definitely give you some different strategies that have worked for other people. So sometimes people find that because it is a little bit a change in routine, doing things that will almost prompt you or remind you of your plans can be really helpful. So for example, if it is a game that you are wanting to play with your kids, taking that out and putting it somewhere in your site so that you can see it. Or even telling the kids or your family that that is the plan so that you have got that support around you to remind you. And I am sure the kids would remind you. Similarly with having a bath, well it is looking at do you have the things ready that you would need? Is your bath ready for you to use? And can you leave things out that are going to remind you that that is the plan you have set for yourself that day?
Karly: That is actually a really good idea. I am going to go home and set that stuff up.
Sarah: Okay, and so in terms of your confidence in being able to put some of these plans in place, Karly? Where do you think you are at, at the moment?
Karly: I am feeling so much more confident. Maybe not a nine, I will say seven. Seven out of ten.
Sarah: Okay, and can you see anything getting in the way for you?
Karly: I think it is just more so doing it. There is such a strong habit for me doing the binge eating. So I think just getting started is the first step.
Sarah: And you are absolutely right. You know, it is not something that we can expect will change overnight, particularly if it is a habit that we have had for a very long time. And sometimes it is even you know, recognising if you are finding that you are binge eating say seven days a week, but even if it is reduced to four days a week, that is still three days less than what you would have been doing for the last you know, months or years, and so it is recognising that small steps make a really big difference.
Karly: Okay, I will keep that in mind.
Sarah: So we might stop the case there.
Jeannie: Thank you so much, Sarah and Karly. I think all of us as GPs are very familiar with the challenge of emotional eating and you know, I think most of us will have heard of the four D’s, Delay, Distract, Deep breathe or Drink water and De-catastrophize. But I think what your role play illustrates is how to apply that in practice. How to encourage the patient to come up with examples of what that might actually, what speaks to them, and what that might look like, how to help the patient remind themselves of what they are intending to do, to think about what the barriers could be and then to be you know, find a strategy to deal with those barriers, and then lastly to be realistic about what can be achieved. So that is really great to see that sort of fully exemplified, so thank you for that. Just before we leave the case and we move to talking about the Get Healthy Service and also to addressing our questions, I did want to ask you, Sarah, in this particular case this is a patient who has a background of depression and anxiety, and the health coach has just started to explore her experience of stress and how that might be affecting her, when would you feel that a patient might actually need to be reviewed by their GP? When would you send them back for medical review?
Sarah: Yes, that is a really good question. So one of the things with the service is that the coach often works with the same person throughout the coaching journey and so they really get to build that rapport and understand. But it also means that they can pick up changes in terms of where they are at both with their physical as well as mental health. And any time there is a red flag or an indication, the coach is really clear in staying within their scope of practice and they would often encourage the person to go back to their GP and to have that discussion.
Jeannie: So that is great to know. So it really is a continuum of care and it really is a team based approach with coaching complimentary to what GPs are advising, and also coaches sending the patient back for review when they detect that that is what is needed. Jeannie: So that is great to know. So it really is a continuum of care and it really is a team based approach with coaching complimentary to what GPs are advising, and also coaches sending the patient back for review when they detect that that is what is needed.
Sarah: Yes, absolutely.
Jeannie: So, let us get on to the New South Wales Get Healthy Service. So can you tell us a little bit more about that, Sarah?
Sarah: Absolutely. So the New South Wales Get Healthy Service is a program that is offered by New South Wales Health to all residents over 16 years of age. It is completely free of charge and it provides patients access to their own health coach who are generally university qualified dieticians and exercise physiologists. And they receive up to 10 coaching calls over a six months period, and as I mentioned it is usually the same coach that works with them, and the coaches schedule in calls like appointments so that they can follow up with the participants and really help them work towards their personal goals. The service is open from Monday to Friday, from 8 a.m. to 8 p.m. so it really does accommodate people’s work schedules, people who might be wanting a call say in the evening or during their lunch break, that kind of thing.
We have been running for just over 10 years and in that time we have had more than 104 thousand people referred to the service and over 2 million visits to the Get Healthy Service website and on average we are seeing weight loss of about 2.8 kg and 4.1 cm reduction in waist circumference. We are also really importantly seeing changes in terms of key outcome behaviours that really affect those lifestyle risk factors we have spoken about. So the change from baseline when they join the service to when they have completed the program of people who have achieved adequate fruit intake has gone from 50% to 74%. Those consuming the five serves of vegetables has gone from 12% to 32%, and people undertaking sufficient physical activity has increased from 39% to 62%. So we are really seeing those improvements there.
If you did have any patients of yours that you were wanting to refer to the service, there are a couple of different ways that you can do that. We have recently launched a new online referral form on the website which allows you to actually save your referral details to the computer or the device so that you are just entering patient details and that gets sent directly to the Get Healthy Service and a coach then calls your patient within the next three business days. You can also access referral forms on Medical Director as well as Best Practice and that can then be emailed or faxed across to the program. And referrals can be made by anyone. So it could be the GP, it could be a practice nurse or if you have got other health professionals or Allied health within your clinic, they can also refer. If you did have someone who is I guess a little bit more contemplative and not ready for a referral right now, and just wanted to think about it, patients can also self-register themselves when they are ready by calling the program or going online and registering their details. There is also the option to receive feedback letters on how your participant is progressing throughout the program and that is as long as you tick for that request and the person consents for you to receive those updates as well.
Jeannie: So we have had a couple of questions come through about the Get Healthy Service. Is it only for New South Wales residents?
Sarah: Yes, so it is a good question. At the moment there are three states that are funding the program, so that is New South Wales, Queensland and South Australia. So it is open to all residents across those three states.
Jeannie: So currently the ACT is not included in the service?
Sarah: No, unfortunately we do not have the service available in the ACT.
Jeannie: And are their eligibility criteria for Get Healthy referrals?
Sarah: Yes, so we are really open in terms of the service. We have a few different tailored programs that can support specific needs. So we have a type 2 diabetes prevention program, a general one around healthy lifestyles. We have one that supports healthy weight gain in pregnancy. So you can refer for specific reasons or goals but the only criteria is that they are a resident in New South Wales, South Australia and Queensland and are over 16 years of age. So just a final note on some of the other programs that are also available in New South Wales which might be helpful as well. And really I am focussing specifically on New South Wales just because that is where I work as part of New South Wales Health. But we have got the Healthy Kids for Professionals as well which is a website that offers free resources, really developed for GPs and health professionals to help assess and manage children who are above a healthy weight. And it has got some really good resources there as well for starting that conversation which can sometimes be a challenging and sensitive topic to raise. They have also had other RACGP webinars in the past that they have presented on and there are videos available there. We have got Go 4 Fun which is a ten week program for New South Wales children aged 7 to thirteen years who are above a healthy weight. And that really focusses on making healthy lifestyle changes as a family to encourage healthy eating habits, more physical activity and addressing self-esteem in kids. And we also have the Aboriginal Knock-Out health challenge which is a community-led lifestyle and weight loss challenge for Aboriginal communities across New South Wales.
Jeannie: Thanks very much, Sarah. It is great to hear about the other kinds of programs and resources that are available. We have only got a few minutes left but we have had a few questions come through which relate to the case study and what it illustrates. So we might go to that.
Jeannie: We had a question earlier on which is really about skills in motivational interviewing. So, what aspects of motivational interviewing do you think were illustrated by the role play that you and Karly just gave us?
Sarah: Yes, so I think there are a lot of different aspects of it, and health coaching really combines a number of the skills from motivational interviewing as well as cognitive behavioural therapy. But at the core of it, it is recognising that the person themselves are the experts in their life, and it really helps to guide the person to come up with their own strategies, identify their own motivators and really it is the coach that is doing the work to support the patient or the participant, where they are at in their own life and health journey. So, helping them to really consider what is realistic, what is left in the past, what is important for right now and what they are ready to do, and where their confidence is at to be able to make those changes.
Jeannie: And so those principles are something that we can use ourselves within a GP consultation where we have a more time limited setting, but they are still relevant.
Sarah: Absolutely. Those principles are really relevant and it is all the principles and skills which I am sure GPs are already using with say, displaying empathy or reflecting when somebody is feeling like they are going through a challenging time or is not having much success as in this case study of weight loss and such, so these skills are all skills that not only health coaches can use, but all health professionals.
Jeannie: And so, the principle is that the participant themselves are the expert in their own life, but what do you say if the person responds with “I do not know” when you ask them how they might overcome a barrier or an obstacle.
Sarah: Yes, and it is a common one so often it is around if they really cannot come up with something themselves, the coaches will then provide them with something that we call a menu of options and I guess you saw a little bit of that displayed with the four D’s example. So when Karly was not able to come up with a solution for how she might address emotional eating, what the coach would then do is offer a menu of different options. So here are all the different things that you could do or you could try to address this challenge that you are experiencing and then asking and reflecting it back to the person to say, would any of these work for you or can you think of anything else that might work for you? So at the end of the day, that decision on which of those strategies they might pick is still in the hands of the patient.
Jeannie: And so with the four D’s strategy, one of our participants has asked whether this is useful for other behaviour change areas such as smoking cessation or alcohol use disorder?
Sarah: Yes, and I know that this has definitely been used in those areas as well.
Jeannie: And in fact the stages of change model was originally developed in the context of smoking.
Sarah: Smoking, that is exactly right.
Jeannie: Right, okay. And then we have a question here, when someone is at the pre-contemplative stage and you are trying to move them to the contemplation stage and then of course to move further along, how, what sort of strategies do you use to try and move things along in that situation?
Sarah: That is a great question and I think that is probably one of the really challenging ones that as health professionals we might find it frustrating and difficult to support someone who does not see it as an issue at all. So really it is understanding where that person’s knowledge is at and importance is at, they are the two key I guess, RICK principles that are really important to focus on for someone who is pre-contemplative. Because it is very likely that they do not understand the link between let us say, healthy eating, physical activity or weight loss, what link that has with diabetes. And they do not then see the link that diabetes might have on their health, not just in the short term but in the long term, and what impact that might then have for them. And it is really important to understand what the motivators are or what is important to that person. Because all of our motivators as individuals are different. So for some it might be as in Karly’s instance, you know, being there for her kids. Setting that good example and being a good role model. That is what is driving her. For other people you know, it might be that they want to lose enough weight to be able to cut their own toe nails or to be able to live independently in their own home, or you know, it is identifying for them what is it that will drive them. What is important enough for them to actually do something different because change is hard. Once you know those motivators, you can help link in that gap in understanding between how them doing something with their lifestyle now will affect their health risk which will affect what is really important to them at the core.
Jeannie: So that is a very individual thing.
Jeannie: What it is that is really important to you and what it is that would give you that motivation.
Sarah: Absolutely. And that is why it is important to take the time to recognise that it is really listening to that person and asking and finding out what it is for that person that you are speaking to and that is once again an example of how you would recognise the patient or the person as the expert in their own life.
Jeannie: And so, when people say for example that they do not have any will power to make lifestyle changes, what is the health coaching strategy to respond to that kind of statement?
Sarah: Good question. So I will break that down into two parts. Often if someone is saying I just do not have the will power to change, to me that sounds like they might not be ready to change. So firstly I would be addressing if they are ready or if it is something that is important to them. And if it is and they are wanting to change but they really feel that they struggle to have that will power or to stay motivated, often what can be really helpful is one of two things. So firstly, explaining that motivation is not something that you either have or you do not have. It is something that fluctuates. So, sometimes you know after a conversation with their coach of their GP, they might feel extremely motivated, but then after a day or two when they have walked past the cake shop or when their favourite you know, movie is on TV, it might be a lot easier to make those options than to choose a healthy choice or go out and do some exercise. So it is recognising that motivation fluctuates. It is not always constant. And then it is having the conversation, well what can you do to really remind you about why you are doing this? You know, what is it that is really driving you to do this? Why is it important to you? And how can you really help to keep it at the forefront of your mind? Because it is not something that automatically comes to us as humans. And then it is working with the person to understand how they can remember that. So in the past I have had people say to me that you know, their motivation might have been their kids or their motivation might be you know, not going down the same path that their parents did. I have then asked them, well what can you do to remind yourself? For some people it might be putting up a photo somewhere that is going to remind them. For others it might be changing their phone screen saver or writing something down or telling other people and speaking about it on a regular basis. For others it is reading or journaling. So for everyone it is different but it is really about keeping those motivators at the forefront of their mind and recognising that it is normal. So if you do find that you sometimes lose motivation, that that is okay, and it is important not to beat yourself up about it.
Jeannie: Well thank you so much, Sarah. And thank you also to Karly who has been part of tonight’s session. I certainly learnt a lot about health coaching tonight and hopefully our participants also have, hopefully they now understand where health coaching fits in the continuum of care, that they are clear on the most appropriate stage of change for a GP to refer a patient for health coaching, understand what the benefits of health coaching are in improving our patient’s health and can explain those benefits to their patients and lastly, are clear on and know what the pathway is to refer patients to existing New South Wales Health services such as the Get Healthy Service. So thanks very much to both of you for tonight.
Sarah: Thanks for having us.
Karly: Thank you.
Sammi: That is great, and I just also want to say thank you again to Jeannie, Sarah and Karly for joining us and also to everybody online. We really hope you enjoyed the session and we hope that you enjoy the rest of your evening.
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