CGPR: Can you explain lifestyle medicine and the role of health coaching?

Dr. Phillips: Lifestyle medicine focuses on enhancing health behaviors to address chronic conditions. It involves optimizing exercise, nurturing relationships, balancing diet and sleep, adjusting substance use, and managing stress. Instead of simply fixing what's broken, as in traditional American medicine, lifestyle medicine aims to prevent and redirect potential issues. Health coaching has emerged alongside lifestyle medicine, with tens of thousands of board-certified health coaches available to consult with clients, primarily over the phone. This anonymity can be beneficial for some people. However, as health coaching is a relatively new field, many coaches also practice without certification. The field does not yet require certification, so there is variability in quality. There are also automated health coaching apps and phone-based groups. Employers often offer health coaching services, as they have been shown to positively impact employee health and ultimately benefit their business (Musich S et al, Am J Health Promot 2015;29(3):147–157). When considering working with a health coach, I recommend finding a coach certified by the National Board for Health and Wellness Coaching.

CGPR: How did you develop an interest in lifestyle medicine?

Dr. Phillips: The driving question for me is “If exercise is so good, why doesn’t everyone do it?” That has been my academic question for about 20 years. If you look at disease, premature death, and health care costs, up to 65% are attributable directly to our health behaviors (Kaplan RM and Milstein A, Ann Fam Med 2019;17(3):267–272). If it’s that important, why isn’t it the main subject in medical school?

CGPR: So, what have you learned? Why doesn’t everyone exercise?

Dr. Phillips: There are many factors affecting behavior change, and in lifestyle medicine, the burden of change falls primarily on the individual. But society has created systemic factors that sustain barriers to health and that more privileged populations do not have to worry about. These include safety concerns due to violence, as well as environmental barriers, such as a lack of sidewalks.

CGPR: As someone who works at a Veterans Affairs (VA) hospital, can you discuss how lifestyle medicine is used to treat mental illness there?

Dr. Phillips: A large number of veterans at the VA are aging and dealing with significant mental health issues. With around eight to nine million enrolled veterans, the VA is essentially a closed system, making veterans our lifelong patients. The “Whole Health” system, developed in 2011, is arguably the largest and most successful experiment in lifestyle medicine to date. Recently, it was recognized by the National Academies as a pioneering approach (National Academies of Sciences, Engineering, and Medicine. Achieving Whole Health: A New Approach for Veterans and the Nation. Washington, DC: The National Academies Press; 2023). Our aim is to achieve a cultural transformation where every conversation and clinical intervention focuses on understanding what matters most to the patient and their purpose in life. We also integrate complementary and integrative medicine practices such as mindfulness, massage, meditation, tai chi, and yoga. Early results from the Whole Health approach at the VA showed that patients involved in the program experienced a decrease in opioid use three times faster than other veterans (www.tinyurl.com/ms2f2cb9).

CGPR: Change is hard for many older adults with mental illnesses. Patients who have engaged in problematic behaviors for decades may be resistant or may return to unhealthy behaviors when their mood decompensates. What have you found helpful for older adults in making lasting changes?

Dr. Phillips: The secret to making changes in health behavior is to attach the change to something that’s of vital importance to a patient. We seek to have every interaction with a patient go back to that individual’s mission, aspiration, and purpose. One of my patients was an older Vietnam veteran with peripheral neuropathy and trouble standing. I asked him what improving his balance would do for him. And he said, “Doc, you remember I told you about my boat? If I can feel the floor and I can improve my balance, I’m going to go on the boat at night; that’s when the magic happens.” I asked what the chances were that he would start balance exercises. He replied: “I’m starting tonight, now that I’m focused on a prize.”

CGPR: That is impressive. When a patient shares their goal, you could approach it from many angles. How do you choose where to start?

Dr. Phillips: In short, we go where the patient wants to go and support them on their journey. Within the Whole Health context, there’s a “Circle of Health.” It has eight domains: 1) movement; 2) recharging and refreshing; 3) surroundings; 4) spirituality; 5) personal development; 6) friends, families, and coworkers; 7) relaxing and healing; 8) food and drink (www.tinyurl.com/bj2775uk). We can hand a physical copy of this circle to the patient, watch their eyes go around, and ask “Which one catches your attention?” We invite the patient to do a personal health inventory, which involves ranking these domains on a scale from 1 to 5. We ask “Where are you with your exercise? Where would you like to be?” We look at an individual’s strengths, then we look at challenges, and then we go back to what matters most to them and what they want to do. We then use their strengths to help their weaknesses.

CGPR: Can you describe an example of how you combine a patient’s strengths and weaknesses to achieve a goal?

Dr. Phillips: I had this delightful older woman who was not getting enough exercise. I suggested a walk after dinner, and she replied “Doctor, you have no idea where I live. I would not know which way to get away from which gunshot.” I then asked what her strength was, and she told me “I’m a churchgoer. I’m all about relationships, all about worship.” I asked her why she wanted to walk, and she mentioned it would help her be strong enough to take care of her grandchildren. I asked her what ideas she had (because any idea I suggested would not be as meaningful). She suggested walking to church on Sundays. I asked her about the violence, to which she replied “The bad people are asleep on Sunday mornings.” She decided to call her friend to walk, rather than drive, to church together the following Sunday.

CGPR: This is a great example of how societal barriers to healthy engagement, such as racism and socioeconomic deprivation, can affect a patient’s goals.

Dr. Phillips: Right, these additional burdens can prevent healthy lifestyles amongst racially and economically minoritized persons.

CGPR: After patients tell you what’s most important to them, what are your next steps?

Dr. Phillips: The key is to always relate the patient’s symptoms (what is holding them back) to the health behavior. You create a shared goal, literally shake on it, and then check in after they do an experiment. Once I realize that my patient is motivated and able to participate, I have a fish on the line. At that point, I can ask for help to get them on board. When a patient is leaning in, I say “Would you like to talk more?” I then help them set goals about their behaviors and let them know we have groups that can provide assistance. If they don’t like groups, I set them up with a health coach.

CGPR: If the fish are biting but they’re not holding on, do you have tricks or tips about how to keep them on the line?

Dr. Phillips: Yes. It can help when clinicians share their personal efforts to improve their health. Even though it’s not a reciprocal relationship, it can be highly motivating to patients when you reveal that you’re engaged in the same process. For example, leaving a bicycle helmet and apple on your desk can improve a patient’s confidence or pique their interest. If they notice it during a visit, you can say “Oh, this bicycle helmet? That’s because I bike to work. It’s only 20 minutes and I get my exercise time in. And this apple? Well, you know, an apple a day…” And then patients find your advice more believable and will be more likely to engage in similar behavior. Another tip to help with motivation may be to talk about other patients. For example, you could say “I learned from another patient recently that they too didn’t want to use a cane, but this guy said he uses hiking poles!” It’s a combination of sharing that you’re trying and then sharing the successes of other patients, how they overcame their challenges. I think groups, community, and connection really help patients stay motivated.

CGPR: What are the main limitations to lifestyle medicine? Are there times when you don’t recommend it?

Dr. Phillips: Although rapidly growing, lifestyle medicine is a relatively new field with a still-evolving infrastructure of education and support. Clinicians may not have all the necessary resources to engage and optimally treat the patient with lifestyle medicine. Also, in instances such as urgent medical care, the focus is on reducing pain and danger more than discussing the patient’s health goals. Lifestyle modifications are largely unsuccessful at helping individuals with obesity achieve a “normal” BMI (without surgery). However, lifestyle medicine can help modestly reduce weight, which improves metabolic biomarkers even if the patient remains overweight or obese. Also, the patient may pursue other beneficial behaviors such as improved sleep, more physical activity, or improved nutrition despite limited change in their weight.

CGPR: Loneliness is associated with multiple mental illnesses, including depression and anxiety. In lifestyle medicine, what can clinicians do to help older adults suffering from loneliness?

Dr. Phillips: The US Surgeon General, Dr. Vivek Murthy, wrote a lovely book, Together:The Healing Power of Connection in a Sometimes Lonely World. (New York, NY: HarperCollins; 2020). We’ve survived over the millennia because we’re social beings. When we lack that social element, loneliness negatively impacts our health. Loneliness was an epidemic even before COVID. Whenever I ask my patients about their social connections, I also ask about how interested they are in joining a group, although this must be a patient-driven and personalized decision. Sometimes I simply tell patients “Going to that church dinner is not just about getting dinner; it actually helps your health.” People need to hear or feel that. When I have an anxious patient who’s not sold on exercise, I tell them “Go for a walk for 10 minutes and see how you feel after. Give me a number before and after.” Or I may say “So you took five minutes to call someone or to spend an extra couple of minutes with them—how does that make you feel?” It doesn’t have to be going to the big event; even microconnections can help.

CGPR: Thank you for your time, Dr. Phillips.