Communication and Behavioral Change Tools: A Primer for Lifestyle Medicine Counseling

  • Robert F. KushnerEmail author
  • Jeffrey I. Mechanick


Effective provider–patient communication is essential for fostering behavior change—the key component of lifestyle medicine. The principles of communication and behavior change are skill based and grounded in scientific theories and models. Communication and counseling must be contextualized to the patients’ economic situation, access to care, social support, culture, and health literacy. Motivational interviewing and shared decision-making—a collaboration process between patients and their providers to reach agreement about a health decision—is an important process in counseling. The five As (Ask, Advise, Assess, Assist, and Arrange) can also be used as an organizational construct for the clinical encounter. The behavioral principles—stages of change, self-determination, health belief model, social cognitive model, theory of planned behavior, and cognitive behavioral therapy—are used in the counseling process.


Communication Behavior change Contextualization Motivational interviewing Shared decision-making 



Cognitive behavioral therapy


Institute of Medicine


Motivational interviewing


Social cognitive theory


shared decision-making


Stages of change


Theory of planned behavior


  1. 1.
    Healthy People 2020. 2014. Accessed 25 Dec 2014.
  2. 2.
    The Office of Behavioral and Social Sciences Research (OBSSR). 2014. Accessed 25 Dec 2014.
  3. 3.
    Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care. A multicenter study. Ann Intern Med. 2010;153:69–75.CrossRefPubMedGoogle Scholar
  4. 4.
    Institute of Medicine. Capturing social and behavioral domains and measures in electronic health records: phase 2. 2014. Accessed 25 Dec 2014.
  5. 5.
    Association of American Medical Colleges. Cultural competence education. Cultural competence for medical students. 2014. Accessed 25 Dec 2014.
  6. 6.
    Berkman ND, Sheridan SL, Donahue KE, et al. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;159:97–107.CrossRefGoogle Scholar
  7. 7.
    Coleman CA, Hudson S, Maine L. Health literacy practices and educational competencies for health professionals: a consensus study. J Health Commun. 2013;18:82–102.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Balint M. The doctor, his patient and the illness. New York: International University Press; 1972.Google Scholar
  9. 9.
    Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423–33.Google Scholar
  10. 10.
    Kravitz RL. Measuring patients’ expectations and requests. Ann Intern Med. 2001;134:881–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda. Have we improved? JAMA. 1999;281:283–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992; 267:2221–2226.Google Scholar
  13. 13.
    Roter D. The enduring and evolving nature of the patient-physician relationship. Patient Educ Couns. 2000;39:5–15.CrossRefPubMedGoogle Scholar
  14. 14.
    Cousin G, Schmid Mast M, Roter DL, Hall JA. Concordance between physician communication style and patient attitudes predicts patient satisfaction. Patient Educ Couns. 2012;87:193–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Schulz PJ, Nakamoto K. Health literacy and patient empowerment in health communication: the importance of separating conjoined twins. Patient Educ Couns. 2013;90:4–11.CrossRefPubMedGoogle Scholar
  16. 16.
    Spreitzer CM. Psychological empowerment in the workplace: dimensions, measurement, and validation. Acad Manage J. 1995;18:1442–65.CrossRefGoogle Scholar
  17. 17.
    Luftey KE, Wishner WJ. Beyond ‘compliance’ is ‘adherence.’ Improving the prospect of diabetes care. Diabetes Care. 1999;22:635–9.CrossRefGoogle Scholar
  18. 18.
    Jaret P. 10 ways to improve patient compliance. Hippocrates. 2001; Feb/Mar: 22–28.Google Scholar
  19. 19.
    Steiner JF, Earnest MA. The language of medication-taking. Ann Intern Med. 2000;132:926–30.CrossRefPubMedGoogle Scholar
  20. 20.
    The Tobacco Use and Dependence Clinical Practice Guideline Panel. A clinical practice guideline for treating tobacco use and dependence. JAMA. 2000;283:3244–54.CrossRefGoogle Scholar
  21. 21.
    Fleming M, Manwell LB. Brief intervention in primary care settings. A primary treatment method for at-risk, problem, and dependent drinkers. Alcohol Res Health. 1999;23:128–37.PubMedGoogle Scholar
  22. 22.
    Vallis M, Piccinini-Vallis H, Sharma AM, et al. Modified 5 As. Minimal intervention for obesity counseling in primary care. Can Fam Physician. 2013;59:27–31.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Fiore MC, Balley WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville: US Dept of Health and Human Services (USDHHS), Public Health Service (PHS); 2000. Report 1-58763-007-9.Google Scholar
  24. 24.
    Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368:6–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Politi MC, Wolin KY, Legarie F. Implementing clinical practice guidelines about health promotion and disease prevention through shared decision making. J Gen Intern Med. 2013;28:838–44.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Sonntag U, Wiesner J, Fahrenkrog S, et al. Motivational interviewing and shared decision making in primary care. Patient Educ Couns. 2012;87:62–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Miller WR, Rollnick S. Motivational interviewing.In: Preparing people for change. 2nd ed. New York: Guilford; 2002. p. 25. (3rd ed).Google Scholar
  28. 28.
    Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient Educ Couns. 2004;53:147–55.CrossRefPubMedGoogle Scholar
  29. 29.
    Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001;32:66–72.CrossRefPubMedGoogle Scholar
  30. 30.
    Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. London: Churchill Livingstone; 1999.Google Scholar
  31. 31.
    Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psych. 2000;55(1):68–78.CrossRefGoogle Scholar
  32. 32.
    Watson DL, Tharp RG. Self-directed behavior. In: Watson DL, Tharp RG, editors. Self-modification for personal adjustment. 8th ed. Belmont: Wadsworth Group; 2002.Google Scholar
  33. 33.
    Prochaska J, DiClemente C. Stages and processes of self-change of smoking. Toward an integrative model of change. J Consult Clin Psych. 1983;51:390–5.CrossRefGoogle Scholar
  34. 34.
    Prochaska JO, DiClimente CC. Toward a comprehensive model of change. In: Miller WR, editor. Treating addictive behaviors. New York: Plenum; 1986. pp. 3–27.CrossRefGoogle Scholar
  35. 35.
    Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38–48.CrossRefPubMedGoogle Scholar
  36. 36.
    Levenson W, Cohen MS, Brandy D, Duffy ED. To change or not to change: ‘Sounds like you have a dilemma’. Ann Intern Med. 2001;135(5):386–90.CrossRefGoogle Scholar
  37. 37.
    Becker MH. The health belief model and sick-role behavior. Health Ed Monogr. 1974;2:409–19.CrossRefGoogle Scholar
  38. 38.
    Janz NK, Champion VL, Strecher VJ. The health belief model. In: Glanz K, Rimer BK, Lewis FM, editors. Health behavior and health education: theory, research, and practice. 3rd ed. San Francisco: Jossey-Bass; 2002. pp. 45–66.Google Scholar
  39. 39.
    Barnanowski T, Cullen KW, Nicklas T, et al. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obes Res 2003;11(Suppl):23–43.CrossRefGoogle Scholar
  40. 40.
    Booth KM, Pinkston MM, Poston WSC. Obesity and the built environment. JADA. 2005;105:S110–S7.CrossRefGoogle Scholar
  41. 41.
    Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems. That was zen, this is tao. Am Psych. 2004;59(4):224–35.CrossRefGoogle Scholar
  42. 42.
    Rosal MC, Ebbeling CB, Lofgren I, et al. Facilitating dietary change: the patient-centered counseling model. JADA. 2001;101:332–338,341.CrossRefGoogle Scholar
  43. 43.
    Aizen I Theory of planned behavior. 2015. Accessed 25 Dec 2015.
  44. 44.
    Brickell TA, Chatzisarantis NL, Pretty GM. Autonomy and control: augmenting the validity of the theory of planned behaviour in predicting exercise. J Health Psychol. 2006;11:51–63.CrossRefPubMedGoogle Scholar
  45. 45.
    Rhodes RE, Bianchard CM, Matheson DH. A multicomponent model of the theory of planned behaviour. Br J Health Psychol. 2006;11(pt 1):119–37.CrossRefPubMedGoogle Scholar
  46. 46.
    Brug J, De Vet E, de Nooijer J, Verplanken B. Predicting fruit consumption; cognitions, intention, and habits. J Nutr Educ Behav. 2006;38:73–81.CrossRefPubMedGoogle Scholar
  47. 47.
    Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. Br J Soc Psychol. 2001;40:471–99.CrossRefPubMedGoogle Scholar
  48. 48.
    Foreyt JP, Poston WSC. What is the role of cognitive-behavior therapy in patient management? Obesity Res. 1998;6(Suppl 1):18–22.CrossRefGoogle Scholar
  49. 49.
    Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441–61.CrossRefPubMedGoogle Scholar
  50. 50.
    Williamson DA, Perrin LA. Behavioral therapy for obesity. Endocrinol Metab Clin. 1996;25(4):943–54.CrossRefGoogle Scholar
  51. 51.
    Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions. An evidence-based approach. Am J Prev Med. 2002;22(4):267–84.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Northwestern Comprehensive Center on ObesityNorthwestern University Feinberg School of MedicineChicagoUSA
  2. 2.Division of Endocrinology, Diabetes and Bone DiseaseIcahn School of Medicine at Mount SinaiNew YorkUSA

Personalised recommendations