Marie-France Hivert, Ross Arena, et al.
Medical Training to Achieve Competency in Lifestyle Counseling
This scientific statement provides guidance in defining fundamentals in medical education and training needed for future physicians to be proficient in lifestyle medicine, focusing on key learning objectives that can be implemented as each program appropriate.
For additional information, please see the full articles:
Hivert M-F, Arena R, Forman DE, Kris-Etherton PM, McBride PE, Pate RR, Spring B, Trilk J, Van Horn LV, Kraus WE; on behalf of the American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health; the Behavior Change Committee, a joint committee of the Council on Lifestyle and Cardiometabolic Health and the Council on Epidemiology and Prevention; the Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; and the Council on Cardiovascular and Stroke Nursing. Medical training to achieve competency in lifestyle counseling: an essential foundation for prevention and treatment of cardiovascular diseases and other chronic medical conditions: a scientific statement from the American Heart Association. Circulation. 2016;134:e308–e327.
Hivert MF, McNeil A, Lavie CJ, Arena R. Training health professionals to deliver healthy living medicine. Progress in Cardiovascular Diseases. 2017;59(5):471-8.
Adequate training of physicians in lifestyle counseling is essential for the prevention and treatment of cardiovascular disease and other NCDs. Many institutions are leaders in medical education for health behavior and lifestyle counseling, but wider implementation of lifestyle counseling education is needed nationally to ensure that future physicians are well prepared to address the main health issues of the 21st century. This AHA statement proposes a framework for US medical school deans and program directors to integrate learning objectives that will improve lifestyle counseling competency among future physicians, including recommendations that physicians become comfortable with engaging in conversations with their patients to initiate the behavior modification process, to make assessments, provide basic advice, and encouragement toward a healthy lifestyle, and to refer patients to other healthcare professionals in the appropriate situations. This AHA statement adds to recommendations from the AAMC and changes in the MCAT to support medical school administration in their curriculum (re)configuration. As often stated, “evaluation drives the curriculum”; consequently, changes in board certification will also be necessary to ensure real change across US institutions.
Behavioral Sciences Knowledge and Skills Development During Undergraduate Medical Training
|Knowledge||Describe counseling steps that foster behavioral change|
|Describe a patient-centered approach and core concepts of major behavior change theories|
|Recognize the expertise of the behavioral counselor and distinguish health professionals who have expertise in supporting specific types of lifestyle behavioral change|
|Skills||Assess lifestyle behaviors and patients’ confidence and readiness to make changes|
|Demonstrate effective patient-centered communication skills to help the patient set behavior change goals and establish a plan|
|Use appropriate behavior change techniques, such as goal setting, self-monitoring, and reinforcement, to support patients in making healthy lifestyle changes|
|Appropriately adapt counseling to patients’ age, sex, race or ethnicity, culture, and preferences|
|Refer to a behavioral counselor or other healthcare professionals with behavioral expertise when appropriate|
Nutritional Assessment and Counseling During Undergraduate Medical Training
|Nutrition assessment||Describe health benefits of recommended dietary patterns and current dietary guidelines for maintenance of health and for the prevention and treatment of diverse medical conditions|
|Assess dietary behaviors and evaluate patients’ habitual food intake|
|Recognize the need for detailed nutritional assessment and referral to RDs and other healthcare professionals with nutritional expertise when appropriate|
|Nutrition diagnosis||Describe pathogenesis of nutrition-related diagnoses|
|Diagnose nutrition-related problems and prioritize them|
|Recognize and use diagnostic labels for documentation in patients’ medical records|
|Communicate effectively with RDs, including understanding the information conveyed by the “problem, etiology, signs, and symptoms” statements commonly used by RDs|
|Nutrition intervention||Assess patients’ confidence and readiness to change toward a healthy lifestyle behavior that includes good nutritional practices|
|Counsel patients on the benefits of evidenced-based recommended nutrition practices for the prevention and treatment of diverse medical conditions|
|Use appropriate behavioral skills and tools to help patients initiate and maintain good nutritional practices|
|Demonstrate effective communication skills with patients and other healthcare professionals with nutritional expertise|
|Appropriately counsel patients according to age, sex, race or ethnicity, culture, and other personal characteristics|
|Recognize the need and appropriate timing for referral to RDs or other healthcare professionals with nutrition expertise with the intent of modifying a nutrition-related behavior|
|Support the implementation of the nutrition intervention with members of the healthcare team|
|Nutrition monitoring and evaluation||Facilitate goal setting and periodic evaluation of dietary recommendations|
|Support behavioral changes by advising the use of monitoring tools in achieving nutrition-related goals|
|Evaluate the health effects of nutrition modifications made by patients|
Physical Activity and Exercise Assessment and Counseling During Undergraduate Medical Training
|Physical activity assessment||Describe the normal physiological responses to an acute bout of exercise and adaptations to aerobic and resistance exercise training|
|Describe health benefits of physical activity for health maintenance and in diverse medical conditions, as well as recommended guidelines for an active lifestyle|
|Assess physical activity behaviors using the appropriate tools for patients who are healthy, have controlled disease, or are living with a disability|
|Recognize the need for additional assessments such as symptom-limited exercise testing and refer to appropriate healthcare professionals or clinical settings|
|Physical activity and exercise prescription||Recognize individuals who do not meet current physical activity recommendations|
|Develop a safe physical activity or exercise prescription for apparently healthy people, those at increased risk for developing a chronic noncommunicable disease, and patients with specific medical conditions|
|Recognize individualized constraints/risks and contraindications to performing physical activity or a structured exercise program and adjust recommendations accordingly|
|Physical activity and exercise counseling, behavioral strategies||Assess patients’ confidence and readiness to change toward a healthy lifestyle behavior as it relates to physical activity and exercise|
|Counsel patients on the benefits of physical activity in health maintenance and for prevention and treatment of specific medical conditions|
|Use appropriate behavioral tools and skills to support patients to initiate or maintain a physical activity plan|
|Demonstrate effective patient communication skills with regard to physical activity and exercise assessment and counseling in all clinical settings|
|Appropriately counsel patients according to age, sex, race or ethnicity, culture, and other personal characteristics|
|Recognize the need for individualized or supervised physical activity programs when referring a patient to appropriate healthcare professionals with physical activity or exercise expertise|
|Support the implementation of the physical activity intervention in close collaboration with other members of the healthcare team|
|Use behavioral strategies to maintain an active lifestyle, including monitoring, goal setting, and periodic reassessment|
|Evaluate the health effects of physical activity modifications with patients and reinforce or adjust the plan accordingly|
|Physician’s personal health||Recognize the importance of an active lifestyle for his or her own quality of life, professional balance, and as a role model for patients|
|Domains||Examples of Formats|
|Knowledge||Large class lectures|
|Integration in problems (for curriculum based on problem-based learning)|
|Self-based learning (readings, interactive e-quiz)|
|Experimental learning experiences (self-monitoring, behavior modification)|
|Clinical skills||Observations of patients’ interviews|
|Video of simulated patients or real patients|
|Patient interview performed by experienced clinician|
|Observation/shadowing of other health professionals (dietitian, kinesiologist)|
|Role-play with peers|
|Practical work with standardized simulated patients|
|Practical work with real patients|
|Feedback from practical work|
|From peers observing/experiencing counseling|
|From trained standardized patients|
|From professor observing role-play or patient counseling|
EXAMPLE: HEALTHY LIVING PRACTITIONER CURRICULUM
The University of Illinois at Chicago launched the Healthy Living Practitioner (HLP) graduate certificate program in the Fall of 2017. Students enrolled in a health professions discipline — including pharmacy, nutrition, nursing, physical / occupational therapy, medicine, dentistry, etc. — are eligible for enrollment as an electives sequence in parallel to their primary education (i.e., stackable credential model). Graduates from these health professions may also exclusively enroll in the HLP certificate program. An HLP rubric was approved to provide the training model with a unique identity and uniform branding across partnering institutions. This educational model, or an evolution of this concept over time, may be a viable educational option for HLM across the health professions.
The courses and learning objectives of this 22 credit certificate program include:
HLP 500. Upstream Prevention: Epidemiology, Economics and Policy
Addresses current public health policy challenges and controversies. Discussions examine changes in health, nutrition, and physical activity policies in the United States in the past few decades and what prompted those changes.
Describe the incidence and prevalence of behaviors that lead to disease states and key health measures and how they begin early in the life course.
- Describe the relationship between LS7 score and other evidence-based risk calculators (e.g., Framingham, ASCVD risk calculator, Reynolds, etc.) and chronic disease risk
- Describe the intersection between unhealthy behaviors, social determinants of health, policy, systems and environment on population health outcomes and economic ramifications.
- Describe policy initiatives centered on improving healthy living characteristics and other preventive measures at a population level
HLP 505. Health Harmonics and Communication
Asks students to evaluate, synthesize, and apply the foundations and fundamental theories and practice of health communication and literacy. It looks at health rhetoric to better understand the conventions used to convey health communication.
- Read as a critical thinker to better translate nutrition and exercise science, both regulated and non-regulated (e.g., supplements for general health and exercise) for a wide and varied audience
- Understand the role of pragmatism to support a two-way health dialogue
- Appreciate the distinction between scientific and anecdotal evidence as it relates to health and wellness and how this distinction influences the two-way health dialogue
- Appreciate that there are many forms of literacy that lack hierarchy but can be orchestrated to effectively and respectfully foster a transaction of health information
HLP 510. Preventive Health Screening
Focuses on health screening assessments, disease prevention, and provides foundational concepts and the tools needed for examining primary care- and community- based chronic disease prevention interventions.
- Be able to use perform a basic health screening assessment, using evidence-based tools, to ascertain the risk for or potential presence of one or more chronic diseases
- Become familiar with current evidence-based risk prediction tools (e.g., LS7, Framingham, ASCVD risk calculator, Reynolds, etc.)
HLP 520. Nutrition for Healthy Living
Provides a clinician’s understanding of nutrition and chronic disease, nutritional assessment, and learn to provide guidance on health nutrition to combat deficiency and degenerative diseases, and when to refer to a diet.
- Understand basic principles of nutrition throughout the life cycle (from embryo to elderly)
- Understand basic concepts of nutrition and chronic disease, for both deficiency and degenerative diseases (arthritis, osteoporosis—non trauma related)
- Be able to perform a basic nutritional assessment
- Be able to provide basic guidance on healthy nutrition
- Be able to provide common nutrition substitutions for culture-specific foods behaviors and values (food focused)
HLP 525. Exercise and Physical Activity for Healthy Living
Introduces students to basic principles of exercise and physical activity in health and disease states. It reviews common exercise testing and PA assessment methods, and outlines exercise prescriptions for healthy and clinical populations.
- Understand basic principles of exercise and physical activity in health and disease states
- Be able to interpret exercise and physical activity assessments
- Be able to provide basic guidance on exercise and physical activity
HLP 530. Behavioral Counseling for Healthy Living
Interrogates theories, principles and health coaching approaches to health behavior change. Evidence based approaches to supporting health behavior change including health coaching are demonstrated.
- Understand challenges surrounding adoption of a healthy living behaviors
- Be able to employ basic behavioral counseling strategies focused on improving LS7 scores, mental health and well-being
- Be able to employ basic behavioral counseling strategies to those facing socioeconomic challenges (e.g., food stamps, government assistance, etc.)
HLP 535. Use of Technology for Healthy Living
Provides students the application of health information systems and informatics in the tracking and managing of Life’s Simple 7 metrics aimed at non-communicable disease prevention and management as pertinent to a health professional.
- Understand basic principles of health information systems and informatics with implications for tracking and managing LS7 characteristics
- Be able to effectively utilize technology (i.e., web, social media, mobile applications, wearable devices, etc.) to track LS7 characteristics and enhance healthy living interventions
- Understand the role of technology in a citizen science approach (e.g., taking photos of built environment — how does the environment promote/hinder healthy living)
HLP 560. Healthy Living Seminar
Introduces students to basic principles of programming for healthy lifestyle practitioner. Models of program management are considered. Issues related to administration and management in a variety of settings are explored.
- Through an inter-professional group project, develop and present a healthy living program proposal in a broad array of settings and environments (e.g., community, workplace, school system, healthcare organization, etc.)
HLP 590. Healthy Living Practicum
Exposes students to a real life experience in programming for healthy living. Students explore models of the management, development, and implementation of lifestyle and disease management and prevention programs.
- Participate in the development and/or implementation of a healthy living program in a broad array of settings and environments (e.g., community, workplace, school system, healthcare organization, etc.)