The Wahls Behavior Change Model for Complex Chronic Diseases: A Clinician’s Guide

Abstract

Alaina N Elliott-Wherry, 1 Jennifer E Lee, 2 Amy M Pearlman, 3 Terry L Wahls 4 1 Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA, USA; 2 College of Nursing, The University of Iowa, Iowa City, IA, USA; 3 Department of Urology, University of Iowa Carver College of Medicine, Iowa City, IA, USA; 4 Department of Internal Medicine-General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA Correspondence: Alaina N Elliott-Wherry, 145 N Riverside Dr, Iowa City, IA, 52242, USA, Tel +1 319 480 8982, Email Behavior change models are used to understand and intervene on health-related behaviors and outcomes. However, there is a gap in the literature regarding how to create and maintain behavior change in patients with complex chronic diseases such as Multiple Sclerosis (MS). To address this gap, the Wahls Behavior Change TM Model (WBCM) (The trademark applies to subsequent mention of the model.) was developed based on existing behavior change theory, empirical evidence, and extensive clinical experience caring for patients with complex chronic diseases. A patient-centered, comprehensive, and multimodal approach, this model provides a framework for understanding and implementing lifestyle behavior change. The overall goals of this paper are to: (1) review existing behavior change theories; (2) introduce the WBCM, including the model's 11 Principles for behavior change in patients with complex chronic diseases; and (3) share how providers can be trained to implement the WBCM. The WBCM can potentially improve short- and longer-term function and quality of life outcomes for people with complex chronic diseases. Keywords: multiple sclerosis, lifestyle medicine, chronic conditions, guidelines, health promotion, adherence Chronic diseases present patients with physical, emotional, and social challenges that often require lifestyle behavior change (eg, improved nutrition, activity levels, stress reduction, coping skills) to enhance quality and quantity of life. For example, Multiple Sclerosis (MS) is a progressive neurodegenerative disease that causes cognitive impairment, 1 muscle weakness, poor balance, difficulty walking, and reduced bladder and bowel control. 2 MS symptoms lead to difficulty with activities of daily living and subsequent diminished quality of life and mood; there is a 35 to 50% lifetime prevalence of anxiety or depression in people with MS. 3 Symptoms may improve with disease-modifying drugs, but there are prohibitive side effects, 4 high costs, 5 and MS drugs do not improve relapses or progressive disability. 6,7 Evidence suggests that behavior choices, such as diet quality and tobacco use, impact MS severity more than genetics. 8 As a result, patients with MS may choose complementary, non-pharmacologic options, such as specialized diets, supplements, physical activity or exercise regimens, and/or stress management. Specialized diets are varied and include the Swank or Paleolithic diets, allergen-free (gluten, milk) and/or polyunsaturated fatty acids (PUFA) supplements, vitamins (eg vitamin D), micronutrients, and/or antioxidants (eg selenium, Gingko biloba , coenzyme Q10). 9 Physical activity and exercise regimens are associated with improved cardiorespiratory function, fatigue, muscle strength, body composition, and disability in people with MS. 10–12 Interventions that combine treatments are also beneficial; A multimodal diet, exercise, stress management, and neuromuscular electrical stimulation program improved fatigue, quality of life, and mood in patients with progressive MS in those with progressive MS. 13–17 While empirical evidence suggests behavior change improves symptoms in people with MS, adherence to MS-related lifestyle changes, such as eating a high-quality diet and exercising, is generally low. 18 Similar low adherence rates, especially for weight loss-related dietary and exercise recommendations, are reported for other chronic diseases such as diabetes, obesity, 19,20 and weight loss among the general population. 21 To increase participation in lifestyle interventions for improved health outcomes, clinicians turn to behavior change models. Behavior change models were developed in the 20th century to explore mechanisms of health habits, and to develop strategies to improve modifiable health behaviors and outcomes. 22,23 Since then, different behavior change models were created to assist with a multitude of health behaviors, including evidence-based tools to improve diet, activity, screen time, smoking, sleep, and medication adherence; overarching emphases ac -Abstract Truncated-