Abstract
Medical fitness and health/wellness coaching (HWC) are emerging health care trends but potential synergistic effects are yet to be studied. Purpose. To determine the impact of integrating HWC within a community-based medical fitness program for patients with chronic health conditions. Methods. A before and after clinical trial, examining 3 frequency levels of coaching sessions, with Journey-to-Wellness (J2W) participants (N = 1306) who were predominately female (76%), aged 12 to 87 years (mean ± SD = 53.54 ± 14.34 years), and referred by their health care provider. Over 3 months, J2W emphasized HWC, exercise, nutrition counseling, and group/interactive events. HWC averaged 4.4 ± 2.5 sessions and was analyzed at 3 levels (0-3; 4-6; 6+ sessions). Pre-post measures were Patient Health Questionnaire (PHQ-9), Positivity, General Anxiety Disorder (GAD-7), Dartmouth Quality of Life (QoL), Lifestyle Nutrition Behavior (LNB), Pain, exercise minutes, weight, waist circumference, and systolic/diastolic blood pressures. Results. J2W intervention significantly (P < .01) improved all outcomes. Between 20% and 43% improvements were observed for PHQ-9, GAD-7, QoL while LNB improved 7.5%, and biometrics between 1% and 2.2%. Greater frequency of HWC enhanced J2W effect for PHQ-9 and QoL with weight and GAD approaching significance. Conclusion. J2W programming produced measurable improvement in health metrics, with greater HWC frequency adding to these beneficial effects, providing a powerful community-based health intervention.
‘Integrated medical fitness centers and associated programs, and health and wellness coaching (HWC), are emerging trends in health care.’
Integrated medical fitness centers and associated programs, and health and wellness coaching (HWC), are emerging trends in health care. Both can be independently effective at preventing and treating lifestyle-related diseases but very little information is available on the effects of combining the two interventions. Thus, the question, if medical fitness programs integrated a HWC model will there be enhanced health outcomes effects for enrolled patients?
Medically integrated health and fitness is an evolving concept grown in the past 30 years from success in using exercise as a prevention and treatment intervention in patient populations coupled with the interest of health care organizations (and personnel) to launch formal programs leveraging an exercise intervention. Exercise programs are shown to improve a patients’ ability to manage weight, diabetes, hypertension, chronic pain, depression, heart failure, and cancer treatment just to list a few. 1 Medical fitness programmatic offerings often move far beyond exercise and can involve health education, nutrition counseling, smoking cessation, stress management, and social engagement opportunities. One such program, Journey to Wellness (J2W) is located in Kalispell, Montana, and is the subject of this report.
Like medical fitness, HWC coaching is a similarly evolving trend with a somewhat shorter history of about 15 years. The potential for HWC as a preventative and treatment process, however, is also impressive. Reports exist describing HWC as useful in helping those with diabetes, obesity, heart failure, cancer, and other lifestyle-related disorders. 2 The coaching process often found to be effective is one employing health care professionals engaging in a patient-centered process emphasizing self-determination, self-efficacy, and appropriate goal setting. 3 In HWC sessions, the clinician is able to forge a trusting relationship with the patient while exploring values, motivators, challenges, strengths, and strategies to successfully foster positive health behavior change. HWC techniques and strategies commonly used include motivational interviewing, mindfulness, and appreciative inquiry among others, and are more fully described elsewhere. 4
While lifestyle-related diseases are a huge health care burden to modern society, large-scale implementation of health-related behavior change remains elusive using the medical system’s “expert advice” approach. Given the excellent potential of medical fitness programming and HWC to positively affect behavior change, it seems reasonable to ask the question, what happens when we combine the two? That is, does adding a HWC emphasis to a medical fitness intervention enhance the benefits associated with that program? While adding a HWC element into a medical fitness program is certainly feasible, and might be hypothesized to augment the beneficial effects of participation, this question has not yet been addressed in the literature. The purpose of the present study was to determine the health impact of integrating a coaching component within a medical fitness program for people with chronic health conditions.
Methods
Design
This study was a clinical investigation using a nonrandomized before and after methodology comparing 3 frequency levels of HWC. Data were collected as a function of normal clinical practices precluding the need for research-related informed consent procedures. Health-related outcomes were measured before and after a 3-month intervention period. Because this study represents a behavioral and public health intervention, our report follows TREND statement recommendations as closely as possible. 5
Setting and Participants
Journey-to-Wellness (J2W) is a wellness program offered in The Summit Medical Fitness Center, a 114,800 square foot medically integrated fitness center on the campus of Kalispell Regional Medical Center, subsidiaries of the Kalispell Regional Healthcare System in Kalispell, Montana. To be J2W eligible, prospective participants required a medical provider’s referral and diagnosis with one or more chronic lifestyle diseases (eg, hypertension, obesity, diabetes). Participants (N = 1306) were mostly female (76%) with an average age of 53.54 ± 14.34 years and a range of 12 to 87 years. They were recruited via word-of-mouth referral with most coming by way of their primary care physician. Our study participants paid a $299 J2W program fee unless they received a scholarship waiving the cost.
Intervention
J2W is a medically integrated fitness and wellness program built on a HWC platform providing participants ample opportunity for exercise activities, social interaction, and education on nutrition, disease management, stress management, and risk factor modification. The J2W staff are all Wellcoaches certified® wellness coaches (www.wellcoaches.com) and come from a variety of professional disciplines including a physician, clinical exercise physiologists, personal trainers, group fitness instructors, clinical social workers, and a mentor for eating disorders. Participants also have access to a facility based registered dietitian, nurse, and respiratory therapist. All coaches held a minimum of a bachelor’s degree in a health-related field and had at least 1 year of coaching experience.
Different from most medical fitness programs, the J2W program was built on a primary HWC platform using associated coaching techniques. This coaching process meets the definition established by Wolever et al 3 and emphasizes strategies such as motivational interviewing, mindfulness, visioning, goal setting, positivity, and accountability. Participants had access to unlimited health coaching based on their individual need. The amount of HWC time allotted ranged from 6 to 14 hours over the course of 3 months. Health coaches were all trained and certified using the Wellcoaches model (Wellcoaches Corp; www.wellcoaches.com). Coaching sessions were scheduled for 30 to 45 minutes with flexibility in duration determined by the client and coach based on his or her individual needs within each session. The only exception was the intake session or first coaching appointment which was scheduled for 90 minutes and included a health appraisal review. While physical activity/exercise training was a primary objective of the program, all participants were taken through a coaching process in order to identify, establish, and progress their own individualized program.
Measures
J2W participants were given a battery of health assessments on-site at the start and again at the end of the 3-month intervention period. Biometrics included blood pressures, body composition (InBody570, www.inbodyusa.com), and abdominal waist circumference measured at the umbilicus. Self-reported questionnaires included minutes per week of exercise, general health, depression, anxiety, positivity, and nutrition habits and thoughts. Specifically, participants completed the Dartmouth COOP Health Survey (DART), the Patient Health Questionnaire (PHQ-9), the General Anxiety Disorder scale (GAD-7), and the Positivity Ratio, all reliable and validated instruments. Additionally, to get information on nutrition practices and pain, the Lifestyle Nutrition Behaviors Questionnaire (LNB) containing a Nutrition Mindfulness subscale (LNB-M), and a simple, single-question Likert-type Visual Analogue Pain Scale (VAS) were utilized.
Analysis
To examine the overall effectiveness of a medical fitness program (ie, J2W), a series of analyses (dependent t-tests) were conducted. Bonferroni correction (P = .004) was made to accommodate the 14 outcome variables examined. Descriptive statistics for before and after intervention, and percent change were also calculated. These analyses were also run by each individual diagnosis to determine if J2W effects differed by patient presentation.
In an attempt to isolate and understand the impact of HWC, a series of 2-way mixed analyses of variance were run on each of the outcomes from the start to the end of the J2W program. Coaching was divided into three groups based on coaching session frequency, less than recommended coaching (0-3 sessions), recommended coaching (4-5 sessions), and greater than recommended coaching (6+ sessions). Using a Bonferroni correction, P was set at .004 as there were 14 outcome variables examined. Analysis of covariance was conducted by diagnosis to examine if extent of coaching impacted outcomes for specific patient presentations.
Results
Program Effects
Tables 1 and 2 illustrate the effectiveness of the J2W program with Table 1 showing each of the psychometric scales (DART, PHQ-9, GAD-7, Positivity, Pain) reflecting quality of life, psychological health, anxiety, positivity, and pain perception (VAS) all improving after completion of the wellness program. Table 1 also shows significantly improved lifestyle habits with exercise participation, eating habits, and nutritional attitudes improved following the wellness program.
Psychometric and Behavioral Outcomes Before and After the J2W Program.
Abbreviations: J2W, Journey-to-Wellness; DART, Dartmouth COOP Health Survey; PHQ-9, Patient Health Questionnaire; GAD-7, General Anxiety Disorder scale; NutrBeh, Lifestyle Nutrition Behaviors Questionnaire; NutrMind, Nutrition Mindfulness subscale.
P < .05; **P < .001.
Biometric Outcomes Before and After the J2W Program.
Abbreviations: J2W, Journey-to-Wellness; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index.
P < .05; **P < .001.
Table 2 contains biometric data which shows wellness program participation led to significantly improved blood pressure and body composition profile measurements at program exit.
Table 3 displays J2W program effects sorted by diagnosis. As can be seen, widespread psychometric benefits were apparent with nearly every patient subpopulation improving DART, PHQ-9, and GAD-7 scores after the wellness program. Exercise participation was also vastly better with all patient presentations reporting an increase in minutes per week (min/wk) of exercise after J2W. Pain, positivity, and nutrition scores improved but less universally with only about half the subpopulations reporting better scores after J2W.
Program Effects by Diagnosis: Before/After J2W.
Abbreviation: J2W, Journey-to-Wellness; n, number participants per patient category; DART, Dartmouth Quality of Life; PHQ-9, Patient Health Questionnaire; GAD-7, General Anxiety Disorder; Pain, visual analog scale pain scale; SBP, systolic blood pressure; DBP, diastolic blood pressure; Wt, weight; BMI, body mass index; BF%, percentage body fat; W, waist circumference; Ex/wk, exercise minutes per week; Pos, positivity ratio; NutBeh, Lifestyle Nutrition Behavior; Mind, Lifestyle Nutrition Mindfulness.
P < .10; *P < .05; **P < .01.
Table 3 can also be examined horizontally demonstrating those with a primary diagnosis of obesity and chronic pain improved significantly across the majority of outcome measures. Most other patient presentations had beneficial results with improvements after the program on about half the outcome measures.
Coaching Effects
Table 4 examines the impact of the frequency of HWC sessions, showing an analysis of 3 levels of coaching participation. Examining Table 4 it can be seen that greater coaching frequency yielded better scores for DART and PHQ-9, with trends for improvement demonstrated in GAD-7 and nutrition behavior. These improvements (DART and PHQ-9) were different between group 1 (0-3 coaching sessions) and groups 2 and 3; but there was no difference for these outcomes between group 2 (4-5 sessions) and group 3 (6+ sessions). However, greater coaching participation did not translate into better scores for other psychometric and behavioral outcomes reported in Table 4. Similar results were seen for biometric data (Table 5). Greater coaching participation resulted in marginally greater reductions in body weight with a related trend in BMI, but more coaching did not yield better program-related improvements in other measures of body composition or blood pressure when compared to participants with less coaching.
Isolating J2W Coaching Effects: Psychometric and Behavioral Outcomes. a
Abbreviations: J2W, Journey-to-Wellness; DART, Dartmouth COOP Health Survey; PHQ-9, Patient Health Questionnaire; GAD-7, General Anxiety Disorder scale; NutrBeh, Lifestyle Nutrition Behaviors Questionnaire; NutrMind, Nutrition Mindfulness subscale.
Significant differences in DART or PHQ-9 existed between group 1 versus 2 or group 1 versus group 3; but there were no significant differences between groups 2 and 3.
1 = 0-3 coaching sessions; 2 = 4-5 coaching sessions; 3 = 6+ coaching sessions.
P < .10; *P < .05; **P < .01; ***P < .001.
Isolating J2W Coaching Effects: Biometric Outcomes.
Abbreviations: J2W, Journey-to-Wellness; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index.
1 = 0-3 coaching sessions; 2 = 4-5 coaching sessions; 3 = 6+ coaching sessions.
P < .10; *P < .05; **P < .01; ***P < .001.
When coaching effects are examined by diagnosis an impact for those suffering with fibromyalgia (Figure 1) and for those with hypertension (Figure 2) is demonstrated. Figure 1 displays greater improvement in DART for those with fibromyalgia who complete greater coaching and this figure is generally representative of the coaching effect seen for several other variables (PHQ-9, GAD-7, Pain, SBP, DBP) in patients with fibromyalgia. BMI, body weight, and percentage body fat were each significantly affected by coaching in hypertensive patients. No other substantial coaching effect patterns could be identified by diagnosis possibly due to declining statistical power in many of these analyses.
Fibromyalgia: DART scores for 3 levels of coaching session frequency following the Journey-to-Wellness program. *P < .01.
Hypertension: Waist circumference for 3 levels of coaching session frequency following the Journey-to-Wellness program. *P < .01.
Discussion
Participation in the J2W, 3-month wellness intervention program, resulted in favorable changes in all outcome variables studied. Patients reported better health status and quality of life, improved body composition and blood pressure, less pain, greater positivity, and better nutritional knowledge and practices. Many of these effects were of substantial magnitude with improvements in psychometric scale variables (eg, PHQ-9, Positivity, GAD-9) reflecting improvements greater than 40% in scores after the 3-month intervention. Furthermore, while not as great as the 40% relative improvements in some psychometric-scaled data, biometric measures (blood pressure, body weight) also improved statistically and clinically over the same short 3-month period. This is one of the first reports describing the benefits of a community-based, medically integrated fitness program.
While medically integrated fitness centers and associated programs are an emerging trend in health care, it is not wholly accurate to say such programs have not been previously studied. It is common to see successful results from cardiac rehabilitation 6 or diabetic treatment 7 programs or other diagnosis-specific populations reported in the literature; however, data reports from a fully integrated, medical fitness center are difficult to find. The J2W program studied presently was open to all those with a chronic medical condition, largely brought on by lifestyle behaviors, with a referral from their medical provider. Most patients presented with multiple diagnoses (eg, diabetes and obesity) but all were treated within the same J2W guidelines.
With just 3 months of J2W participation, those with chronic pain, obesity, cardiac problems, and even cancer improved on a minimum of four outcome variables but most patients saw improvement on at least 10 of the 14 outcomes measured. Reports of better health status and quality of life (PHQ-9 and DART) were ubiquitous across all 12 diagnoses studied. Patients with obesity and chronic pain may have benefitted the most from J2W with improvements in 13 of 14 outcome measures. Those patients who may have the most to gain from a reduction in fat deposition (diabetic, prediabetic, obese, hypertensive) experienced strong changes in all body composition–related variables. Although a before-after study design is not ideal, it is rare for patients in this age group (mean age = 53.5 years) to spontaneously improve in these outcome measures over 3 months; in fact, it is much more common for health deterioration to accompany the passage of even a short period of time. 8 It is very likely that J2W medically integrated programming with coaching was the primary reason for the widespread health improvement experienced by our patients, regardless of diagnosis.
It appears evident that such a program (ie, multidisciplinary and coaching based) can be highly successful at improving patient health while addressing a multitude of lifestyle diseases and patient limitations. J2W provided a multifaceted approach to treatment, emphasizing exercise programming and health coaching while also providing participants social and educational experiences. It seems clear this holistic programming is effective; however, it is more difficult to examine the component effects of J2W. One of our primary aims, however, was to evaluate the distinct impact of the HWC intervention across the various diagnoses.
When comparing HWC frequency, several J2W program effects were shown to be greater for those doing more health coaching. Patients completing 4 or more coaching sessions over the 3-month intervention reported better health status and quality of life while trending toward feelings of less anxiety than those who participated in less coaching. Furthermore, participation in at least 4 coaching sessions led to better nutrition behaviors and weight management when compared with those who did a lesser number of coaching sessions. This result is similar to previous findings demonstrating health coaching benefits to those struggling with weight management. 9
While health coaching provided selective benefits by patient primary diagnosis (eg, hypertensives had greater weight loss with 6 or more coaching sessions), these effects within diagnostic groups were not widespread. Smaller sample size lowered statistical power in these subsample analyses making it difficult to isolate an impact of coaching. Furthermore, the general effect of J2W staffing (all certified coaches) may have obscured the coaching session impact as clinicians providing attention and support were readily available during clinic visits several times each week outside of scheduled coaching sessions. In other words, a potential for beneficial incidental coaching was not easy to account for in the J2W environment. Arguments for exercise professionals employing HWC skills during an exercise training or rehabilitation session exist.10,11 While it is not possible to properly conduct a full coaching session during an exercise session it is feasible to receive encouragement, positive feedback, education, and develop a supportive relationship. When you consider the potential for numerous J2W patient-clinician interactions during exercise, education sessions, and social activities, adding additional HWC sessions might become less likely to have a significant effect on outcomes. In other words, the impact of patient-clinician interaction may achieve a ceiling effect making it difficult to isolate the impact of adding formal coaching sessions.
Health coaching is an emerging adjunct to medical intervention and a systematic review generally supports a beneficial effect to the coaching process. 12 However, it can be difficult to isolate the impact of the HWC intervention within a more encompassing wellness treatment program like J2W. The effects of regular exercise training are powerful and can include well-known psychological 13 and physiological benefits. 14 J2W participants increased exercise participation by an average of 300% when considering minutes of exercise per week. When such an exercise treatment is initiated concurrently with coaching, the effects of coaching may be more difficult to partial out. In fact, the great increase in exercise participation may be a function of the J2W staff and possibly their HWC training. In summary, we were able to demonstrate beneficial impacts of coaching within the J2W program, but more widespread coaching effects may be difficult to isolate from the larger J2W program effect.
Limitations
This study utilized a nonrandomized before and after methodology with data collected as a function of the normal clinical practice. As such, the study results are limited by the lack of a noncoached control group. While we recognize this limitation, we believe that this large-scale HWC study embedded within a lifestyle medicine practice is representative of real-world application and makes a unique contribution to the literature. Moreover, these results should provide the impetus for a follow-up trial using careful controls and possibly randomization. We did not compare results between coaches, partly because some participants may have seen more than one coach during their time in the program. As all the program coaches received similar training and standardized measures and methods were utilized, we have assumed the influence of differences between our coaches’ techniques are small and effects not substantial.
Conclusion
In conclusion, a community-based medical fitness program emphasizing exercise and health coaching was very beneficial to a large variety of patient diagnostic presentations. As an isolated component, health coaching clearly added to the programming effects of J2W. However, it may best to simply consider health coaching as an integral component of this successful medical fitness program. Such programs can provide widespread health benefits to patients otherwise limited by lifestyle diseases.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
Not applicable, because this article does not contain any studies with human or animal subjects.
Informed Consent
Not applicable, because this article does not contain any studies with human or animal subjects.
Trial Registration
Not applicable, because this article does not contain any clinical trials.