By Dr Odette Vos

As lifestyle medicine practitioners, we often find ourselves caught in a familiar cycle: patients presenting with chronic disease symptoms, motivated at least verbally for change, and yet, weeks or months later, we find ourselves treating the same issues again. Despite our best efforts, despite evidence-based coaching, the message doesn’t always seem to land. So, I ask myself why?

Why do some patients adopt healthy changes and flourish, while others remain locked in a frustrating loop of illness, short-term clinical improvement, and relapse, without meaningful lifestyle transformation?

Is it because modern medicine is too effective at managing symptoms in the short term, leading to complacency? Or are we not delivering the right information at the right time, in the right way?

I believe it’s the latter, and previous evidence supports that belief.

 Behaviour Change: The Cornerstone of Lasting Health

At the heart of lifestyle medicine lies one fundamental principle: behaviour change. Without it, knowledge and prescriptions or even the most holistic, plant-forward, whole-person-focused approach amount to little more than good intentions.

The body of evidence is growing, and behavioural interventions can delay or prevent type 2 diabetes more effectively than some pharmacological treatments when implemented early and consistently [1], even significantly reducing cardiac events in patients with coronary artery disease, sometimes reversing the condition altogether [2]. So why, with this wealth of evidence, do we continue to face a sluggish uptake, both at the patient and health system level?

The answer lies in our understanding (or lack thereof) of how behaviour change actually works in a clinical context. Behaviour change is a process, not just a prescription.

We often treat lifestyle advice as if it’s a one-size-fits-all intervention. But patients don’t just need to know what to change, they need support in how and when to change it.

This is where the Transtheoretical Model (TTM) or Stages of Change Model becomes essential in clinical practice. Developed by Prochaska and DiClemente, this model recognizes that change is a process, with individuals moving through various stages:

1. Precontemplation – No intention to change behaviour soon.
2. Contemplation – Acknowledging the problem but not ready to act.
3. Preparation – Getting ready to change and seeking help.
4. Action – Actively making lifestyle changes.
5. Maintenance – Sustaining new behaviour and preventing relapse.
6. Relapse (optional stage) – Returning to old habits, often part of the process and can be avoided by implementing follow-up consults with your patient.

Understanding where your patient is in these stages of change allows you to tailor your intervention accordingly, giving the right advice, at the right time, in the right way.

Behaviour Change Sleep Case Study

This month, we focus on sleep, a common issue with far-reaching effects on metabolic, cardiovascular, and mental health. Addressing poor sleep habits illustrates the importance of an individualized, stage-appropriate intervention.

Patient 1 – Precontemplation

A 45-year-old CEO reports chronic fatigue but denies sleep being an issue. Here, education is key. Consider using data and visuals (e.g., wearable sleep tracking) to build awareness. This is not the time for rigid bedtime routines but to plant seeds.

Patient 2 – Contemplation

A new mother admits her sleep is disrupted and wants to improve it, but is overwhelmed. Here, motivational interviewing and normalizing her struggle through reassurance can help her move toward preparation.

Patient 3 – Preparation

A university student recognizes that poor sleep hygiene is affecting his grades. This is the moment for shared planning: perhaps limiting screen usage before bed, setting wind-down routines at night, and introducing meditation.

Patient 4 – Action

A shift worker has committed to a sleep protocol. Your role here is to support and manage accountability in his action steps, to track progress, celebrate wins, and adjust when life interrupts to reach the final goal.

Patient 5 – Maintenance

A retired man has practiced good sleep hygiene for months. Reinforcement and family support from his wife can keep him on track.

Each of these patients could be given the same lifestyle advice, but only one will be ready to implement it immediately. Without tailoring our approach, our guidance may fall on deaf ears- not because patients aren’t listening, but because we aren’t meeting them where they are in their lifestyle journey. The success of any lifestyle intervention is dependent on:

• The patient’s intention- Why are they here? What outcome matters to them? Is it a recent health scare?
• Their stage in the behaviour change cycle- Are they ready to implement behaviour change?
• Environmental and social realities – Do they have family that is dependent on them for their health? What other commitments affect how they prioritise their health?
• Our ability to coach them into action- not just telling, but guiding, adjusting, listening, COACHING!

We often focus too heavily on clinical outcomes, forgetting that behind every HbA1c reduction or drop in LDL is a lived human experience that needs empathy, structure, and trust.

As lifestyle medicine continues to fight for its rightful place as a specialty at the frontlines of chronic disease care, we must shift from a model of knowledge dissemination to a model of behavioural partnership. Tailoring our lifestyle medicine interventions to patient readiness.

Let us be more than providers of information. Let us be interpreters of intention, navigators of readiness, and coaches of real-life transformation.

Lifestyle change is not a one-size-fits-all behaviour change prescription but a journey, and we must meet our patients exactly where they are, walk alongside them, and help them believe that lasting change is not only possible but deeply worth it.

References

1. Haw JS, Galaviz KI, Straus AN, et al. Long-term sustainability of diabetes prevention approaches: a systematic review and meta-analysis of randomized clinical trials. Lancet Diabetes Endocrinol. 2015;3(12):968–976.
2. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA Intern Med. 2014;174(9):1429–1435.
3. Raihan N, Cogburn M. Stages of Change Theory. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556005