Sara Horst, MD, on Health Coaching for Patients With IBD

In this video, Dr Horst provides guidance on how to help patients with inflammatory bowel disease make small lifestyle changes that can lead to better outcomes through health coaching.


Sara Horst, MD, is an associate professor of medicine with the IBD Clinic at Vanderbilt University Medical Center in Nashville, Tennessee.




Hi, I'm Sara Horst, a gastroenterologist at Vanderbilt University Medical Center, who specializes in the care of patients with IBD. I also have research interest in the area of psychosocial outcomes and medication adherence.

As one digs into these areas, one thing that I started to learn over and over again is the science of behavior change. Behavior change involves helping a patient if they're engaged in an unhealthy behavior, and how to change that, and how difficult that actually is.

As I learned about it and I started a research study, I started to learn all kinds of way of helping change behavior for patients. The area I focused on was something called health coaching. I was able to go through a course about this, and I wanted to share a few things that I learned that have become practical for me in clinic.

First things first, the bottom line of any behavior change involves something called the stages of change. For a patient, you have to understand where they are and their willingness to alter a behavior.

For instance, if you have somebody in clinic who's smoking, and you ask them if they'd be interested in smoking cessation, and you get absolutely no, obviously, there is less benefit to focusing a lot of energy on that patient at that current moment. You need to find a patient who is interested in moving the needle a little bit. If you do, here are a few takeaway points to think about helping them.

First, the best way to make a long‑standing behavior change is for the individual to come up with a plan themselves. Humans are rather contrary beings. If we're told what to do, the vast majority of people's first instinct is to think, "No way."

The bottom line to health coaching and behavior change is this—find the value behind what would motivate the patient, have them make the plan, say it out loud multiple times, and then put it into action.

The best way to make that work typically is the second key, which is to find small actionable incremental steps towards a larger goal, and finally, the key in health coaching. When a patient makes one behavior change successfully, it doesn't even matter what it is. They have improved health behaviors overall.

A study in the diabetes population showed significant increases in medication adherence and decreases in hemoglobin A1c when the patients underwent a successful behavior change, which most of the time had nothing to do with medication adherence or dealing with their diabetes, which is pretty important.

We can help patients get healthier overall by making one small change in one area of their life. I'm sure at this point people are asking, "How in the world can you implement the ideas behind behavior change in health coaching in a 15- or 20‑minute clinic visit?"

I'll give you 5 tips and I can generally get through this in about 5 to 10 minutes. Let's think about your patient with fatigue. Their IBD is in remission. Their vitamin levels are normal. You and the patient have figured out that the best next step might be to work on some sort of behavioral change and lifestyle change.

For this patient, let's just say they want to eat better or exercise. Tip number 1: When you talk to a patient about behavior change, use permissive language. Now this was a little bit hard for me to do at first, but with that, as any habit, it has become more second nature. It's really helpful in collaborating with a patient.


For example, instead of saying, “Of course you're going to stop going to McDonald's every day for lunch," say, "If it's OK with you, I'm going to talk a little bit about poor eating and lack of exercise, and how that might be contributing to your fatigue. Then maybe we could come up with some ideas together about how to improve this."

It's a tiny change, but you're giving control back to the patient, and this is the key in collaborative relationships. I use it a lot now. It doesn't take a lot more time, which was one thing that I was worried about.

Tip number 2. When you're talking about lifestyle change, the most important thing I mentioned before is making sure you understand the value behind the change. You don't have a lot of time to do this. The way I try to get to it is asking 1 question.

For instance, for this patient, what's the single most important thing you want to do when you get this fatigue better? I get all kinds of answers. "I won't be tired at work," "I want to golf again," "I want to be able to go to more of my kids' soccer games." I write this down and I go back to our future conversations. It's the value to help motivate them for change.

Tip number 3. Do you have a little bit of value introduced? I acknowledge that to get to this behavior change will be hard, and I set a little bit of an agenda about how we can get things moving in the right direction.

For this patient, "I don't have to tell you that trying to find time and energy to do this may seem impossible. I wonder if we could try to help you find a small move towards exercise that you could work on for the next visit, and then it might help you without feeling overwhelmed."

Tip number 4. This is a big help for me. I usually ask the patient if there is a time when they've been successful with a behavior change in the past. This helps the patient understand that they've been successful before and gives them ideas for a path forward. For our patient, "When have you been able to exercise regularly before, and how did that look for you?"

Tip number 5. Usually the patient is talking a little bit by this point. At this point, because we have limited time, I usually get a little bit more directed, and I help them find a small step towards a possible plan.

For our patient, "It sounds like walking is going to be the best place to start. Let's think of 1 to 2 times per week where you can work in it, and I'll ask you about it the next time you come." Don't forget to follow‑up. I'll write a sentence in the chart about the step, and I make sure to ask him about it. The next time success deserves all the praise.

This might seem overwhelming or not feasible, and for a lot of sick patients it isn't. We also take care of a lot of patients with IBD who are doing well. I think moving the needle towards healthy behaviors is something we as physicians shouldn't forget about.

Remember, there's research that patients who end up healthier in one area of their life, spill all these healthier habits into other areas. That could be smoking cessation, medication adherence, etc. Your patients can end up healthier with IBD, but don't ignore that lifestyle behaviors can affect their disease. Thanks.