Strategies for behavior change in patients with heart failure.

Appropriate management of chronic heart failure and its signs and symptoms requires a considerable amount of participation by patients. Behavioral changes that prevent or minimize signs and symptoms and disease progression are just as important as the medications prescribed to treat the heart failure. The most difficult lifestyle changes include smoking cessation, weight loss, and restriction of dietary sodium. The Transtheoretical Model is a framework for assessing and addressing the concept of readiness for behavior change, which occurs in a 6-step process. The model consists of 3 dimensions: the stages of change, the processes of change on which interventions are based, and the action criteria for actual behavior. The stages of change are discussed, and interventions are presented to assist patients with heart failure in progressing through those stages toward maintenance of changed lifestyle behaviors. Methods for measuring the level of readiness for change of patients with heart failure are also presented, because correct staging is required before appropriate interventions matched to a patient's stage can be delivered.     

The transtheoretical model and primary care: "The Times They Are A Changin'"

PURPOSE: To identify the transtheoretical model and the five stages of change that assist to bring about behavioral change. A case study is presented to illustrate how the model can be applied by primary care nurse practitioners (NPs) to assist patients toward a healthier lifestyle. DATA SOURCES: Scientific literature, theoretical framework, and case study. CONCLUSIONS: The transtheoretical model has implications in primary care to assist NPs in assessing what stage a patient may be in, offering encouragement to promote a healthier lifestyle change, and reassessing the patient to maintain the desired healthy behavior. IMPLICATIONS FOR PRACTICE: Primary care NPs can use the transtheoretical model to better advance patients into a healthy behavioral change. Documentation of the current stage a patient is in can promote continuity of care among providers, outline specific health promotion initiatives to enhance patient care, and provide documentation during regulatory inspections.     

Process of behavioral change as it relates to intentional physical activity.

During the past 100 years, America has changed from an agrarian society, where the intent of physical activity was to produce needed materials, to a postindustrial society, where 60% of American adults are not regularly physically active and 25% are not active at all. With sedentary lifestyle and its attendant consequences on the rise, the occupational health nurse can increase individuals' knowledge, facilitate their decision making, and motivate them to try new behaviors and change existing behaviors. The occupational health nurse can use a model to organize individual workers' information and clarify strategies to promote behavior change. The goal is to decrease the morbidity and mortality associated with sedentary lifestyles of American workers by using the model when individuals present to the occupational health service. Individuals benefit from health care professionals who understand personal risks and communicate strategies to address barriers and concerns when they consider behavior changes such as increasing physical activity.     

Metabolic syndrome: time for action

The constellation of dyslipidemia (hypertriglyceridemia and low levels of high-density lipoprotein cholesterol), elevated blood pressure, impaired glucose tolerance, and central obesity is identified now as metabolic syndrome, also called syndrome X. Soon, metabolic syndrome will overtake cigarette smoking as the number one risk factor for heart disease among the U.S. population. The National Cholesterol Education Program-Adult Treatment Panel III has identified metabolic syndrome as an indication for vigorous lifestyle intervention. Effective interventions include diet, exercise, and judicious use of pharmacologic agents to address specific risk factors. Weight loss significantly improves all aspects of metabolic syndrome. Increasing physical activity and decreasing caloric intake by reducing portion sizes will improve metabolic syndrome abnormalities, even in the absence of weight loss. Specific dietary changes that are appropriate for addressing different aspects of the syndrome include reducing saturated fat intake to lower insulin resistance, reducing sodium intake to lower blood pressure, and reducing high-glycemic-index carbohydrate intake to lower triglyceride levels. A diet that includes more fruits, vegetables, whole grains, monounsaturated fats, and low-fat dairy products will benefit most patients with metabolic syndrome. Family physicians can be more effective in helping patients to change their lifestyle behaviors by assessing each patient for the presence of specific risk factors, clearly communicating these risk factors to patients, identifying appropriate interventions to address specific risks, and assisting patients in identifying barriers to behavior change.     

Facilitating treatment adherence with lifestyle changes in diabetes

Healthy eating and increased physical activity can prevent or delay diabetes and its complications. Techniques that facilitate adherence to these lifestyle changes can be adapted to primary care. Often, the patient's readiness to work toward change must be developed gradually. To prepare patients who are reluctant to change, it is effective to assess and address their conviction and confidence. Patients facing the long-term task of making lifestyle changes benefit from assistance in setting highly specific behavior-outcome goals and short-term behavior targets. Individualization is achieved by tailoring these goals and targets to the patient's preferences and progress, building the patient's confidence in small steps, and implementing more intensive interventions according to a stepped-care model. At each office visit, physician follow-up of the patient's self-monitored goals and targets enhances motivation and allows further customization of the plan. A coaching approach can be used to encourage positive choices, develop self-sufficiency, and assist the patient in identifying and overcoming barriers. More intensive intervention using a team approach maximizes adherence.     

Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes

PURPOSE: To explore strategies for improving patient outcomes in type 2 diabetes. DATA SOURCES: The literature related to type 2 diabetes management, behavior change, communication, diabetes self-management, and coaching. CONCLUSIONS: The strategies currently suggested for improving patient outcomes, e.g., increasing provider adherence to evidence-based management guidelines, streamlining practice systems, and promoting patient lifestyle changes through intensive education, have produced mixed outcomes. Of the many complexities involved in managing type 2 diabetes, motivating patients to change behavior may be the most challenging. A suggestion for improving patient self-management of type 2 diabetes is to use coaching communication within a framework of behavior change in the context of the primary care encounter between nurse practitioners (NPs) and their patients. IMPLICATIONS FOR PRACTICE: Given the varied outcomes of current strategies, coaching by NPs may provide a feasible alternative for improving patient outcomes in type 2 diabetes. Coaching communication can be implemented during office visits as an intervention without cost. To effectively implement this approach, however, practicing NPs and NP students need more formal education in this expected but underdeveloped NP role competency. NPs are called upon to contribute to the body of knowledge needed to validate the merits of coaching for their patients.     

A 'stages of change' approach to helping patients change behavior

Helping patients change behavior is an important role for family physicians. Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions. The concepts of "patient noncompliance" and motivation often focus on patient failure. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the change process. In this article, we review the Transtheoretical Model of Change, also known as the Stages of Change model, and discuss its application to the family practice setting. The Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the office to promote discussion.     

Motivational interviewing: helping patients move toward change

Motivational Interviewing (MI) is a valuable tool for nurses to help patients address behavior change. MI has been found effective for helping patients with multiple chronic conditions, adherence issues, and lifestyle issues change their health behaviors. For Christian nurses, MI is consistent with biblical principles and can be seen as a form of ministry. This article overviews the process of MI, stages of change, and offers direction for further learning.     

Readiness for behavioral changes in patients with heart failure.

BACKGROUND: Successful self-care in heart failure often requires lifestyle changes such as avoiding sodium, excess fluid intake, alcohol, and tobacco; exercising regularly; and losing weight. The Transtheoretical Model, a framework for making behavioral changes, proposes that change requires a series of stages. OBJECTIVES: To identify the stage of readiness for change in 6 lifestyle behaviors important in heart failure and to determine differences in signs and symptoms of heart failure, self-reported knowledge of the disease, and self-reported behavior between patients who have taken action and patients who have not. METHOD: A mail survey of 250 patients with heart failure. RESULTS: Most respondents reported consistent avoidance of tobacco (90.6%), alcohol (87.9%), sodium (81%), and excess fluid (72.6%) and regular participation in exercise (67.1%) and trying to lose weight (64.7%). Yet only 38.7% had a regular exercise program, and 94.2% had eaten high-sodium foods in the preceding 24 hours. Knowledge of heart failure was low (mean score, 67.4%) and did not differ by stage of change. Only 30.4% of the respondents were at their desired weight, and most overweight subjects had been trying to lose weight for more than 6 months. CONCLUSIONS: Although respondents thought they were consistently adhering to recommended guidelines for changes in lifestyle, actual reported behaviors did not always support this evaluation. Use of the stage of change tool to assess stage of readiness to make lifestyle changes may not work well in patients with heart failure, perhaps because of the number and complexity of the changes needed.     

Lifestyle changes: effects on an obese patient

Obesity is often caused by an unhealthy lifestyle, which is a composite of various individual behaviors. Nurses may assist obese patients to lose weight and avoid chronic disease by identifying risky lifestyle behaviors and helping to develop improvement strategies. This article describes the nursing experience of the authors in caring for an obese patient who had made several unsuccessful attempts to reduce weight. An intervention approach was used to review the patient's lifestyle. Using self-regulation theory, the authors identified that the patient's fat-related daily behavior included: lack of exercise, high-fat diet, and daily snacks consumed even late at night. The authors also helped the patient discover the reasons underlying his fat- related behavior and his previous failed attempts to lose weight and to develop a feasible improved approach that considered such. After six weeks of care, the patient's body weight had reduced and body fat and body mass index had decreased with no relapse. The patient further lost significant weight and body fat during the three-month follow up period. The authors would like to share with nursing professionals this approach to weight loss, with the hope that this case study can contribute to medical efforts to help obese patients not only lose weight but also prevent chronic illnesses.     

Mediators of lifestyle behavior change in Native Hawaiians: initial findings from the Native Hawaiian Diabetes Intervention Program

OBJECTIVE: To examine the association of stage of change with diet and exercise behaviors in response to a lifestyle intervention for Native Hawaiians (NHs). RESEARCH DESIGN AND METHODS: A family ('ohana) support lifestyle intervention was compared with a standard intervention in NHs with or at risk for diabetes in two rural communities in Hawaii (n = 147). Stage of change, as a hypothesized mediator of behavior change, and dietary and exercise behaviors were measured at baseline and at 1 year postintervention. RESULTS: Stage of change was significantly associated with positive dietary and exercise behaviors. NHs receiving the 'ohana support (OS) intervention were more likely to advance from pre-action to action/maintenance for fat intake and physical activity than the group who received the standard intervention. Participants in the OS group who advanced from pre-action to action/maintenance showed more improvement in fat intake and physical activity than those in the standard group. CONCLUSIONS: These initial findings suggest that stage of change is an important factor in mediating lifestyle behavior changes in persons with or at risk for diabetes and merits further study among minority populations at high risk for diabetes.     

One theoretical framework for cardiovascular disease prevention in women

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality for women in the United States. Vulnerable and underserved women are even less likely to participate in healthy lifestyle behaviors to prevent CVD than the general US population. Many women are not aware that they are at risk for CVD and do not modify unhealthy lifestyle behaviors to reduce their risks for CVD. Healthcare providers may not promote awareness of CVD or consistently counsel female patients concerning lifestyle behavior modifications to reduce their risks for CVD. "The Evidence-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update: A Guideline From the American Heart Association" provides a guide for healthcare providers to help women lower their risk for heart disease. By using a theoretical approach, nurses can facilitate implementation of these evidence-based guidelines to help women reduce their risks for CVD. Commonly used intrapersonal, interpersonal, and organizational- and community-level health behavior change theories that can be used to effectively promote CVD risk reduction in women will be discussed. The theoretical basis for changing CVD risk behaviors in women can be applied by using the PRECEDE-PROCEED Model to guide planning, implementing, and evaluating health behavior programs. The purpose of this article was to help nurses improve healthcare delivery by using the PRECEDE-PROCEED Model as a theoretical framework to guide CVD risk reduction efforts for women.     

Dynamic health promotion for the geriatric population.

The documents Healthy People 2000 and its update, Healthy People 2010, have helped focus national attention on the neglected areas of disease prevention and health promotion and maintenance. Despite increasing awareness and the proliferation of research that demonstrates the effectiveness of a healthy lifestyle for disease prevention, patients and healthcare professionals continue to struggle with an effective approach to effecting healthy lifestyle strategies. The inclusion of health promotion goals into care plans seldom is enough to create positive behavioral changes in a patient. Understanding what motivates an older individual to adopt healthy habits and what behavioral change process the individual must take to be successful is a key starting point for the rehabilitation nurse dedicated to the promotion of health and wellness. The transtheoretical model of change (TTM) is an approach that can be used to create an atmosphere for the adoption of healthy lifestyle practices, and assist in the behavioral change process necessary to promote older adults' success in this endeavor.     

Reducing the personal risk of perceived disease: the chiropractic patients' self-care endeavor

OBJECTIVE: It has been suggested that clinicians should be looking at new ways to enhance the self-care of their patients. Patient education is one strategy that primary providers may use. This study investigates the behavior of chiropractic patients to identify whether they are using widely published community health information messages to reduce their personally perceived risk of various diseases. METHODS: An exploratory study of chiropractic patients was undertaken to investigate the health-relevant behaviors of patients. Purposive sampling of 9 Australian chiropractic clinics was undertaken. Convenience sampling of patients attending these clinics resulted in the participation of 102 patients. All participants completed a questionnaire, and data were collected and collated into a series of case studies that described some behaviors of participants that might have influenced their risk of acquiring disease. The study was limited to diseases for which participants believed they were at risk. RESULTS: A substantial number of participants had undergone a screening procedure as recommended by health authorities. The 67 participants who believed they were at risk for one or more of the conditions listed were more likely to have complied. In addition, all participants made certain healthy lifestyle choices. However, implementation of those lifestyle choices that would reduce the personal risk of perceived diseases was sporadic. CONCLUSION: The behavior of participants in this study suggests that many chiropractic patients would benefit from additional personalized health information messages. The use of information brochures in chiropractic clinics may not alone lead to a lifestyle change.     

Determinants of health-promotive behavior. A review of current research

The determinants of health promotive-behavior are proposed by Pender in the HPM. The exact impact of the various variables on singular behaviors or a lifestyle index, however, is far from conclusive. All the proposed factors have been supported through research, at least in part, as either directly or indirectly influencing the intent to participate in different health behaviors. The difficulty in concluding which variables are most critical is perhaps due to the variety of definitions, theoretical approaches (from different disciplines), and research methods. Of primary concern to this author is the overlap of activities among different "patterns" of behavior and the various definitions of such behavioral patterns. Little evidence exists on how specific types of behaviors relate to one another. Thus, knowing the determinants of a lifestyle index, for example, may be insignificant if the goal of nursing is to target priority behaviors that may indeed be influenced by more significant variables. For example, a person's perception of control may be a significant predictor of lifestyle behaviors in general; however, this variable may not impact on the person's decision to engage in changes related to exercise or activity behavior. Hence, because the motives behind various behaviors may be different, it seems more prudent to invest our research efforts on the impact of various factors on singular behaviors rather than lifestyle patterns. Finally, the efforts of nursing research on health behavior have been directed primarily at explaining the impact of various individual perceptions on the likelihood of behavior. Such focus has revealed some evidence of the significance of these variables, yet much unexplained variance remains. Perhaps it would be more prudent to direct attention at those variables such as situational or environmental factors that may impede or act as a cue to healthy behavior. Because the explanation of behavior has been individually focused (perhaps due to an "individualizing" theme in nursing education), the impact of the ecological model of behavior tends to be dismissed or underrated in nursing research. Knowledge of the impact of societal factors on behavior may be more appropriate to planning strategies for various groups rather than the behavioristic approaches that separate people from their social, physical, and economic environments. Thus, personal lifestyles may not be a simple matter of informed choice, and attention to the complex processes of societal opportunities, cultural interpretations, and group-specific attitudes must be studied further.     

Nursing experience using motivational interview techniques in caring for an obese patient with type 2 diabetes

Global prevalence and incidence of diabetes for all age groups are increasing. Research evidence reveals that lifestyle modification can both significantly improve glycemic control and delay complications. Obese patients suffering from type 2 Diabetes Mellitus in particular require food therapy and weight reduction through behavior modification in order to regain a healthy quality of life. This article used motivational interviews and the transtheoretical model to develop a behavioral change strategy to set health behavior as well as to assist the patient to attain weight reduction and glycemic control goals. Over the study period (April 30, 2009 to June 10, 2009), the patient's weight declined from 93.4kg to 90kg. Also, her blood sugar is gradually stable. Because of the effectiveness of behavior modification, the patient exhibited sustained motivation to continue maintaining diet control, which reflects motivation is an important component for behavior modification. The authors would like to share this case report to provide nursing professionals with a reference for using motivational interview techniques and transtheoretical model.     

中青年冠心病患者健康行为及其影响因素研究

目的了解中青年冠心病健康行为水平及其影响因素。方法采用一般资料问卷、健康促进生活方式量表、冠心病健康信念问卷、社会支持评定量表对400例中青年冠心病患者进行问卷调查。结果中青年冠心病患者健康行为总分为(130.32±24.24)分,条目均分为(2.57±0.49)分。婚姻状况、病程、维护健康动机、社会支持是影响中青年冠心病患者健康行为的主要因素。结论中青年冠心病患者的健康行为水平有待提高,建议制订健康教育方案要充分考虑中青年冠心病患者健康行为的主要影响因素,改变不健康的生活方式,促进其身心健康。     

Potential of Lifestyle Changes for Reducing the Risk of Developing Rheumatoid Arthritis: Is an Ounce of Prevention Worth a Pound of Cure?

PurposeLifestyle may be important in the development of rheumatoid arthritis (RA). Therefore, changing behaviors may delay or even prevent RA onset. This article reviews the evidence basis for the associations of lifestyle factors with RA risk and considers future directions for possible interventions to reduce RA risk.MethodsThe literature was reviewed for cross-sectional studies, case-control studies, cohort studies, and clinical trials investigating potentially modifiable lifestyle factors and RA risk or surrogate outcomes on the path toward development such as RA-related autoimmunity or inflammatory arthritis. The evidence related to cigarette smoking, excess weight, dietary intake, physical activity, and dental health for RA risk were summarized.FindingsCigarette smoking has the strongest evidence base as a modifiable lifestyle behavior for increased seropositive RA risk. Smoking may increase seropositive RA risk through gene–environment interactions, increasing inflammation and citrullination locally in pulmonary/oral mucosa or systemically, thereby inducing RA-related autoimmunity. Prolonged smoking cessation may reduce seropositive RA risk. Evidence suggests that excess weight can increase RA risk, although this effect may differ according to sex, serologic status, and age at RA onset. TDietary intake may also affect RA risk: overall healthier patterns, high fish/omega-3 polyunsaturated fatty acid consumption, and moderate alcohol intake may reduce RA risk, whereas caffeine and sugar-sweetened soda consumption might increase RA risk. The impact of physical activity is less clear, but high levels may reduce RA risk. Periodontal disease might induce citrullination and RA-related autoimmunity, but the effect of dental hygiene behaviors on RA risk is unclear. Although the effect size estimates for these lifestyle factors on RA risk are generally modest, there may be relatively large public health benefits for targeted interventions given the high prevalence of these unhealthy behaviors. With the exception of smoking cessation, the impact of behavior change of these lifestyle factors on subsequent RA risk has not been established. Nearly all of the evidence for lifestyle factors and RA risk were derived from observational studies.ImplicationsThere are many potentially modifiable lifestyle factors that may affect RA risk. Improving health behaviors could have large public health benefits for RA risk given the high prevalence of many of the RA risk-related lifestyle factors. However, future research is needed to establish the effects of lifestyle changes on RA risk or surrogate outcomes such as RA-related autoimmunity or inflammatory arthritis.