Wednesday, August 21, 2013

AHS13 - Going Forward: The Power of Health Coaching

Figure 1. Ancestral Health Symposium by the numbers

(Disclosure: I am the co-founder of a health coaching company called Sweat and Butter, so I am biased in my views on health coaching.  However, my optimism that health coaching is a plausible solution to the most complicated patient problems was the driving force behind the establishment of Sweat and Butter.) 

The Who's Who of Paleo
The 3rd Annual Ancestral Health Symposium (AHS) took place this weekend in Atlanta, Georgia.  It was a meeting of the minds among physicians, dietitians, optometrists, researchers, biochemists, athletic trainers, chiropractors, anthropologists, biologists, and neuroscientists.  I've been practicing a "primal" lifestyle for nearly four years now, yet the conference was a refreshing change of pace because the ancestral health community is beginning to more heavily attract the likes of economists, historians, philosophers, statisticians, and politicians.  It also continues to drive an outcropping of grass-fed, all-natural, free-range, sustainble edibles and toiletries, evidenced by the various vendors at the event's expo.  Farmers are showing up to share their difficulties in balancing food politics with consumer demand.  Lawyers are dropping in on the conversation in an effort to strategize how to take the food industry to court for their sins.  This whole thing is becoming fun!

I first discovered the Paleo diet when I began working out at Crossfit South Hills in 2010.  Prior to that, I had been the typical wheat-guzzling triathlete, but this new diet worked for me.  It was easy to follow: eat loads of vegetables, buy quality animal products, minimize dairy consumption, and cut out wheat, processed foods, and vegetable oils.  It was transformative to my performance, but, more importantly, it opened my eyes to a community of people that were working towards the same goal: get healthy while utilizing sustainable means for the sake of a healthier environment and community.

An Interface Between Biological Science and Patient-Clients
My conversations with attendees and speakers this weekend have made me think more deeply about the need for health coaches to meet the demands of our nation's growing health problems.  Health coaches could potentially serve to interface medical science with patient-client lifestyle modification.  In the five minutes that I spend with a patient in the clinic, I don't have time to review diet, sleep, stress, relationships, and movement.  It would be hugely beneficial if a health coach could work with a patient in between office visits to ensure that they have the resources and know-how to develop healthy habits for the betterment of their health.  

If we could collect data on which interventions work best to control various health conditions and for how long these interventions need to be applied, we may be able to convince health care payers that health coaching is a worthwhile, cost-saving mechanism for improving the population's health.  The problem with this is that we've shown that patient compliance is poor for many interventions, even prescription pills, which require little effort on the part of the patient.  Perhaps the problem is that people tend to not take advantage of services that they don't value.  In developing some of these ideas with Jacob Egbert of Primal RX, he drew comparison to business training services that were gifted to him. Despite a high monetary value, he would go months without even cracking into a service that he received at no cost to himself.  On the other hand, paying for a service made him feel obligated to stick with it over the long haul.  

If They Try It, They'll Be Sold
Despite a long list of hesitations and excuses, even the most difficult patients respond to lifestyle modifications as a means of addressing their health woes provided they actually do what their physician recommends.  The holy grail to getting patients to subscribe to lifestyle modification recommendations is for them to try it.  Robb Wolf dedicates an entire chapter to this principle in his book, The Paleo Solution.  If a patient sticks through a cleaner diet for 30 days, they'll likely see improvements in energy levels, mood, sleep, weight, and digestion.  Add in some movement and an hour or two more sleep per day, and they'll start feeling great!  Indeed, you can modify your lifestyle ad infinitum and continue to see improvements.  Patients will likely grab the wheel after they see that losing weight or improving an inflammatory process is possible, but they have to see and feel those results first.  The health coach's job is to hold a patient-client's hand until they're convinced that they can hold the reigns and start calling the shots.  And this occurs not long after the patient sees the remarkable results that lifestyle modification can bring.

The reason that lifestyle modification - when done correctly - works for most people is analogous to a mattress salesman persuading you to make a purchase by allowing you to sleep in one of the store's display beds for a few nights.  SOLD! Once a Sweat and Butter coach gets you over that threshold, the patient-client will begin practicing healthier habits on their own, but it's unclear how to define or quantify that threshold.  I have seen it take anywhere from weeks to years for this transition to take place.  Assuming we know what's best for a patient's health (yes, we have a pretty good idea at this point), many questions remain: How long does a person need to be led by the hand in order to feel empowered to take their health into their own hands?  What objective or subjective metrics are important for them to be satisfied with their progress?  How do we measure these objectives? We need data to answer these questions.

What I would like to see is a comprehensive health program whereby a physician makes lifestyle recommendations to patients (old news).  Then, a well-paid health coach spends as much time as necessary with the patient to ensure that they are empowered to make further lifestyle tweaks autonomously.  Health coaching is a relatively new principle, but Iora Health has been utilizing coaches for several years. They have a few clinics across the country, and they hire nine coaches for every two physicians.  Their primary health outcomes have improved across the board, and they have plans to open up more clinics across the country.  Although the evidence that they report is only moderate in strength, it's a start.  This concept is theoretically sound, but it's going to take a lot more data to prove that it works.  

Our healthcare system needs an interface between the medical sciences and our patient population.  This interface, ideally, would be (a) sympathetic to patient needs, (b) designed around healthy habit formation for long-term compliance, and (c) utilize well-trained, passionate coaches.  The conventional health insurance model requires zero responsibility on the part of the consumer.  If a patient doesn't have to pay for it, then they likely won't ascribe to it.  But they also hate to disappoint their doctors. With only fifteen minutes per office visit with a physician, there is little time for sufficient Q&A about lifestyle.  It's too easy for patients to simply nod and smile as we ask scripted questions like, "Have you been eating more vegetables?"  Health insurance may pay for this, but it doesn't mean that they'll utilize the service.  After all, prescription pill compliance is a huge issue, and this only requires swallowing some pills once or twice per day, let alone making changes to your eating, exercise, and sleep habits.  

If you are a member of a Crossfit gym managed by trainers and owners that are fully invested in improving the health of their clientele or if you found your physician through the Paleo Physicians Network, then CONGRATULATIONS!  You've already got a health coach!  For the rest of the population, consider this: what if a personal health coach met with you bi-monthly instead of the once per three (or six) month schedule to which patients have grown accustomed with their physicians? Furthermore, these coaches would work with you to overcome the emotional and psychological barriers you have to healthy habits.  They could help you plant gardens, teach you cooking methods, and guide you towards better sleep hygiene.  They would also address the [lack of a] support system at home, give you a shoulder to lean on when things get tough, whatever it takes...Would this system work for you?

I've been watching these transformations happen for several years now with even the most stubborn clients, and I think it would.  Many people across the world have been playing a game of marco polo with health professionals.  They're yelling "Marco!", and the best that our system has been able to provide is a 15-minute office visit whereby we physicians have little time to address sleep, stress, food, movement, and relationships as components of a healthy lifestyle.  It's no surprise that the system doesn't work!  The deep seated beliefs and misconceptions about diet and exercise alone require more delicate handling, and patients need to be held responsible for enacting change when they're given access to good advice.  Sweat and Butter and the Paleo community at large are screaming "Polo!"

Monetary Investment vs Handholding
Unless our government crumbles to the ground because of the growing national debt, we're stuck with a system that prizes a large, expensive, and convoluted model for health care.  If we want to do right by our patients, we need to make access to the system affordable.  As I mentioned before, when consumers aren't connected to the price of a service, they begin to take it for granted.  An office visit is devalued by the fact that it was seemingly given to them for a small co-pay, and the physician-patient relationship has been warped as a result.  Physicians are expected to take care of a patient's needs without a patient blinking an eye at the price.  The current system claims to be making great efforts to improve preventative care, yet it doesn't place any responsibility on the patient to work on implementing healthy lifestyle modifications in between visits.  I see two ways in which we can get people to value a lifestyle modification program:

1) Patients must invest monetarily (i.e. Fee-for service)
The problem with this model is that it only works for those who can afford to buy in.  In an ideal world, the income inequality gap wouldn't be so large, but that's the way things go for the time being.  The success of the Crossfit community is that its clients prioritize a relatively large sum of money (anywhere from $95 up to $300 per month) to be a part of a community that works to engage them in lifestyle change.  Crossfit gym members prioritize the price of their monthly membership because the workouts and community helped them realize a sense of well-being that they had never before experienced.  When Obamacare kicks in in 2014, the incentive for the underinsured to take better care of themselves will also be removed.  The bottom line is that if you are relying on health insurance to keep you healthy, we've proven that our current health care model is inadequate, and a big part of the problem is that patients don't have to big deeply into their pockets when they get sick.

2) Patients are under regular supervision
If a health coach was part of the deal, the patients would be held accountable for meeting the recommendations made by their physicians.  The key here is to get them to try a few small modifications.  They'll see the results in their weight, mood, digestion, etc. and this is important for the formation of healthy habits.  They don't have to pay for the health coach out of pocket, but they certainly have to answer to them.  When they start to feel great, they'll be hooked for life.  The many success stories that come out of the Paleo community corroborate the notion that an improvement in symptoms (e.g. patient experience) can drive healthy habit formation.  The price tag becomes a moot point.

Of the two options, the latter might have a better chance of succeeding once we scale this up.  The patient is accountable to a health coach in between physician check-ups, and, eventually, time spent with the health coach could be weaned until the patient doesn't need to have their hand held any further.  They will have developed healthy habits because they began to experience subjective improvements in their well-being.  Their biometrics (e.g. lipid panel, hip-to-waist ratio, blood pressure, etc.) also will have improved.  Get a health coach into a household, and we'll likely see their positive improvements taken up by family members and furthermore driven deeply into communities.  Until health insurance subscribes to this concept, health coaching may only remain a solution to the growing health concerns of the affluent (e.g. health coaching as an out-of-pocket expense), as even very affordable programs such as those offered by Sweat and Butter aren't accessible by the lowest income groups, but it's reasonable to assume that it can eventually be applied to all sociodemographic groups. 

Data Drives Decisions
Collecting data to answer our research questions is the tricky part.  Getting clients in private health coaching companies to sign on as part of a research project may be easier than it seems, but we won't know for sure until we try.  Biometrics are necessary, and technology companies such as Dan's Plan might provide important insight into how to track a patient-client's progress over time and help them identity for themselves common trends over the course of their transformation.  Food journaling and subjective markers like a sense of general well-being will also play a role.  

The face of healthcare is changing, and we need to consider a variety of disciplines in finding an answer to our nation's growing health woes.  The Paleo community is becoming a confluence of hundreds of disciplines, providing the unique opportunity for academics and practitioners to share ideas and hypothesize such solutions.  More importantly, we're starting to put this stuff into practice.  Eating a Paleo diet makes sense, and it works.  Thousands of patient-clients can vouch for that.  But how do we make it accessible to all?  Our nation's health care model doesn't work, so perhaps health coaching and technology are, in the very least, worth a shot. 

When people start to feel healthy, they will become subscribers to lifestyle recommendations.  They will begin voting politically through sustainable food purchases, they will become more productive at work, and they will be generally happier.  If you've found things that work, you need to continue to espouse your views to friends and family.  If they won't buy into your ideas, then a health coach can step in and work their magic.  Our coaches have the gift of empathy, enabling them to pick through a client's excuses by addressing the psychological and emotional stressors that have kept them from stepping out of their comfort zone and towards a healthier alternative.  With proven modifications in hand (e.g. Paleo dieting, high intensity training, sleep science, etc.),  human psychology and behavioral science can be applied to create lasting changes.   For the time being, health coaching works remarkably well as a private service.  Once we get some data, we can hopefully convince health insurance providers and corporate work places to subscribe to this concept, too.

Nathan Riley is a 2014 MD candidate at Temple University School of Medicine.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD. He can be reached at

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  1. Excellent write-up! I've been thinking a lot about these things myself the past few years. A health coach is useful for people who have trouble implementing their doctor's advice for lifestyle changes. A coach is also helpful for people who are not getting what they need from their doctors. I'm imagining somebody that is very knowledgable about the medical system and would be able to sit down with a patient and assure them that they will help them navigate the system. (I'm speaking from personal experience of desperately trying to figure out what was making me sick - and not making any progress during my <15 minute doctor appointments. I was referred to countless specialists but none of them had the time to look at the whole picture, and I did not have a good primary care doctor to fill this role.)

  2. Excellent points, Tess. I think you hit the nail on the head in your assessment of the role of health coaches. Some of our clients have such incredible stories and really complicated reasons behind the way that they eat and things that they stress. Physicians are trained to identify and respond to the consequences of a less than ideal environment's influences on our bodies and minds, but they aren't great at managing the stressors and past life experiences that may be debilitating patients' efforts to develop healthy habits (I'm speaking from experience as a medical student that is freshly through the system). The worst part of all of this is that many people view health in one of two ways: skinny or fat. In my experience, the former would benefit even more than the latter. People that want to lose weight tend to nip a problematic lifestyle in the bud, whereas the thin people convince themselves that they're doing everything right simply because they're thing. These are complicated topics!


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