The Health Coach Approach: A Secondary Analysis on The Association Between Remote Health Wellness Coaching and Body Appreciation

doi:10.21203/rs.3.rs-4914383/v1

Background: Body image and body appreciation (BA) are often considered a young adult issue, but the importance of body image as a factor contributing to wellness persists across the lifespan. The study's purpose was to test (1) the effect of a 3-month health-and-wellness coaching (HWC) program on BA and (2) whether baseline measures of physical and mental health were related to changes in BA. 100 women completed a 3-month HWC program where BA and mental and physical health measures were collected twice.

Methods: A stepwise linear regression was conducted using measures of physical and mental health with BA as the outcome.

Results: A higher level of baseline depression was linked to more improvement in BA post-intervention (β=0.033, p<0.05), while higher baseline muscular endurance was linked to less improvement in BA at post-intervention (β= -0.022, p<0.01).

Conclusion:Results suggest that a 3-month HWC program has potential for improving BA, with stronger results possible among women with higher levels of depression at the start of the intervention.

Health Wellness Coaching

Body Appreciation

Chronic Illness

Rural Health

Women’s Health

Health and Wellness Coaching (HWC) is a patient-focused approach to preventing and mitigating chronic disease-related risk factors (1, 2). Research has provided empirical support for some psychological and physical benefits associated with HWC for individuals with chronic lifestyle risk factors (e.g., sedentary, overweight/obese, physically inactivity) such as reduced cholesterol, increased physical activity, and decreased depression symptoms (2–4). A potential unexplored factor involved in understanding the relationship of HWC and mental health is body image, which is defined as an “individual’s cognitive or affective evaluation of their body or appearance with a positive or negative valence” (5). Despite the potential benefits of HWC on various health outcomes, there has been limited examination of the factors involved in the relationship. Within a sport context, research has shown that coaches’ communication and behavior can significantly impact an athletes' body image, either positively or negatively (6). Considering the widespread prevalence of body image concerns, it's crucial for research to explore whether HWC can play a role in promoting and supporting positive body image (7, 8).

Body appreciation (BA) is a significant public health concern due to its demonstrated associations with stress levels, self-rated health, and depressive symptoms (9). These relationships are particularly prevalent among women (10, 11). More specifically, women who are appreciative towards their body might be more prone to engage in behaviors that are health promotive, making body image important to overall health (12). Individuals with low body image, and thus lower BA, have been found to have higher propensity for eating disorders, depression, and overall, report lower quality of life (13, 14). While the benefits of HWC and healthy body image are promising, the relationship between HWC, health outcomes, and body image is not well understood, particularly among high-risk groups.

Body Image among Adults

Many studies on eating disorders tend to examine an individual's body image more from a negative perspective rather than a positive one. (15–18). However, an increasing amount of literature draws attention to BA, the positive aspect of body image. BA has been described as holding favorable opinions of one’s body that is perceived as accepting and respecting the body (19). BA is an important part of body image research because, with its strong mental and physical health correlates, it is a viable intervention target (9). While recognition of the important role of BA is growing, the available research is not as robust, especially in populations with chronic health conditions.

People who have greater BA tend to show positive connections with various aspects like body esteem, favorable body evaluation, and indices of psychological well-being (e.g., self-esteem, self-compassion, life satisfaction, proactive coping, and positive affect) (9, 19). High levels of BA in individuals are inversely related to body dissatisfaction, social physique anxiety, body shame, body surveillance, and body checking behaviors (19, 20). Indeed, current evidence suggests there is an overall positive relationship between health promoting behaviors and BA. Individuals with higher BA are more likely to participate in preventative medical care and seek medical attention (12). Additionally, BA is positively associated with self-perceived physical health and intuitive eating behaviors (21, 22). There is some evidence linking physical health directly to BA, but only in young healthy populations (21).

A previous meta-analysis has discussed the impact of HWC on obesity, heart disease, and overall wellness (2). Similarly, a systemic review highlighted the positive benefits of HWC on obesity rates in participants (2). Research found that HWC interventions targeting heart disease increased medication adherence, decreased hospitalizations, and increased positive mental health (23–25). Additionally, HWC has had positive effects on overall health. In a recent meta-analysis conducted by Sforzo et al. (2020), out of the 41 studies included that focused on obesity and wellness, 15 specifically addressed various aspects of physical activity. Notably, none of these studies focused on measured muscular strength or endurance, but rather focused on physical activity time.

Addressing Body Image

While there are some body image prevention and intervention programs that target adult female populations and address low BA, such interventions are limited in number and population diversity (26, 27). Recent efforts have been made in female rheumatoid arthritis populations to reduce the prevalence of negative body image, particularly considering the influence of body functionality on adult’s self-perception of body image (28). Importantly, HWC has been identified as a patient-centered, collaborative approach utilizing behavioral strategies (e.g., motivational interviewing, positive psychology, and self-determination) that goes beyond averting and mitigating health-related risk factors and outcomes associated with the prevention and management of chronic diseases (1), and therefore has a significant influence on adult’s mental and physical health. However, the impact of changes in overall BA scores on mental and physical health outcome measures has not been clearly established. Therefore, this study aims to determine how HWC impacts BA and to evaluate the connection between this change and the mental and physical health factors supported by HWC.

Current Study

The present study examines the use of HWC as a form of intervention to increase BA and overall body image (29). Building on previous interventions that specifically targeted BA or body image, this intervention took a holistic approach to HWC, with coaches providing health screening, education, and goal setting in line with participant needs and preferences. This study fills a gap in the existing literature by increasing our understanding of the relationship between HWC and body image. Specifically, the present study (1) examined the relationship of a 3-month HWC program on BA and (2) assessed how change in BA score was related to physical and mental health at baseline. Our primary hypothesis was that completion of a HWC program would be related to a positive change in BA score, with mental health status at baseline positively affecting this change. Additionally, we hypothesized that physical health status at baseline would negatively affect the positive change in BA.

Participants

A total of 100 women aged 23 to 80 years old (M = 51.9, SD = 13.8) participated in a HWC program, Montana Journey to Wellness. The participants were recruited from a predominantly white population, with 89.9% identifying as White, 7.1% as American Indian or Alaska Native, and 3% as other. To be eligible to participate in the Montana Journey to Wellness program, individuals must receive a referral from a medical provider and a diagnosis of one or more health-related chronic risk-factors or diseases (e.g., hypertension, obesity, type 2-diabetes). Recruitment materials were disseminated through word of mouth, e-newsletter across the hospitals, and medical provider offices.

Measures

All details related to the study were explained to participants prior to the study and upon confirmed consent, data capturing physical and mental health status were collected. Measures on physical health included the sit-to-stand test, the two-minute march test, body mass index (BMI, kg/m²), and body composition (% body fat). Measures on psychological health included depression, anxiety, and BA scores. Demographic information also was collected. Baseline (pre intervention) and 3-month (post intervention) data was collected via four Qualtrics surveys.

Body Appreciation (BA). The validated 13-item Likert-type scale was used to assess BA in participants (18). Respondents were asked questions regarding their opinions on their bodies, with responses based on a 5-point-scale ranging from (1) Never to (5) Always. BA was indicated by the means of the items, with higher scores indicating higher levels of BA in participants. The Cronbach’s alpha reliabilities for BA was 0.93 (18).

Anxiety. The 7-item General Anxiety Disorder-7 (GAD-7) scale was utilized to assess participants’ anxiety at baseline (30). Respondents were asked about their recent experience of anxiety symptoms. Responses were provided using a 4-point-scale ranging from (0) not at all to (3) nearly every day. Anxiety was indicated by the sum of the 7 items, resulting in a score between 0 and 21 (30, 31). We utilized the established cutoffs to identify different levels of anxiety (30, 31). More specifically, a score of 0–4 was considered minimal anxiety, a score of 5–9 was considered mild anxiety, a score of 10–14 was considered moderate anxiety, and a score of 15 or above was considered severe anxiety (31). The Cronbach’s alpha reliability for GAD-7 was 0.89 (30, 31).

Depression. The validated 9-item depression scale, Patient Health Questionnaire-9 (PHQ-9), was used to measure depression in participants (32). Respondents were asked recent frequency of depressive symptoms. Responses were provided using a 4-point-scale ranging from (0) not at all to (3) nearly every day. The responses of the 9 items were summed, with a maximum score of 27 points. A score of 10 or higher was considered mild major depression; a score of 15 or higher indicated moderate major depression, and a score of 20 or higher indicated severe major depression (33). The Cronbach’s alpha reliabilities for PHQ-9 was 0.89 (34).

Sit-to-Stand. The sit and stand test were used to assess leg strength, endurance, balance, and overall physical activity level. It is a physical performance test where participants go from a seated position to a standing position repeatedly for 20 seconds (35, 36).

Two-minute step. The two-minute step test is an exercise capacity test that requires the participant to march in place as fast as they can while raising their knees to a height midway between their patella and iliac crest when standing (37). A systematic review of functional capacity exercise tests found that higher scores on the two-minutes step are a marker of higher activity and fitness level (38).

Body Mass Index. The Body Mass Index (BMI) is a ratio of a participant’s weight to height squared. BMI has historically been used to assess an individual’s risk of weight related illnesses (39). Although BMI fails to distinguish between body fat, muscle mass, or bone, it is a well-accepted marker to identify increased risk of obesity-related disease, health conditions, and mortality, specifically with a BMI ≥ 30.0 kg/m² (40).

Body Composition. Body fat percentage was measured using the Tanita BIA-bioelectrical impedance analysis 570 (Tanita, Tokyo Japan). Bioelectrical impedance has been found to be a valid form of body fat percentage measurement in comparison to other methods like skinfold fat and hydrostatic weighing (36, 41, 42).(40–42)

Demographics. Age and ethnicity were acquired using self-reported data collected at baseline. Age and ethnicity were acquired utilizing Qualtrics to gather self-reported baseline data.

Procedure

The Montana Journey to Wellness program was informed by an existing coaching program, Journey to Wellness, which is based on HWC concepts (29). The program provides opportunities for exercise and education on nutrition, disease management, stress management, and risk factor modification. All coaches were Wellcoaches certified® wellness coaches (www.wellcoaches.com) with at least one year of coaching experience and a bachelor’s or advanced degree in a health-related field. Health and wellness coaching incorporates motivational interviewing, mindfulness, goal setting, visioning, positivity, and participant accountability (2, 43, 44). Participants had access to bi-weekly 30–45-minute coaching sessions, based on their individual needs. While the primary focus of these sessions was physical activity and exercise training; goals, plans, and coaching session content was tailored to each participant following the initial intake visit. Baseline and post program information was collected during two 90-minute coaching sessions.

Statistical Analysis

Participant information was collected using Qualtrics (Qualtrics, Provo, UT), while the analysis was conducted using RStudio (RStudio, Boston, MA). Before analysis all data collected was checked for missing and outlier values, and normality. Descriptive statistics were run for all continuous variables. For any categorical variables frequencies were ran. Less than 3% of data used for analysis was missing at random, therefore no data was imputed (45). To ascertain the change in BA following HWC, paired t-tests were conducted. To further examine the association between physical health and mental health on the changes in BA, multiple statistical procedures were conducted. First, the change in BA for each participant was calculated. Next, correlations between physical health measures, mental health measures, and changes in BA were conducted. Finally, a stepwise linear regression was conducted, with change in BA as the dependent variable, and health measures as independent variables (46). Only variables with p < 0.05 were included in the final model.

Descriptive and correlation results for all dependent variables are presented in Table 1. The sit-to-stand test, the 2-minute march, and depression scores are significantly correlated with change in BA. As change in BA scores increase, both the baseline of the total number of sit-to-stands and the baseline 2-minute march test score decreased. Further, the results indicated that as change in BA scores increase, the baseline depression scores also increased.

A paired t-test found that there was a statistical difference between body appreciation at baseline and post intervention (p < 0.01). This indicated that body appreciation did increase during the intervention.

Table 1

**Descriptive Statistics and Correlations of Dependent Variables** *Note.* BMI = Body Mass Index; PHQ-9 = Patient Health Questionnaire; GAD-7 = Generalized Anxiety Disorder assessment.
Measure	Mean	SD	Correlation (p value)
Sit to stand	16.82	5.18	-0.26 (0.01)*
2-minute march	98.26	19.69	-0.21 (0.05)*
BMI	32.81	7.11	0.08 (0.46)
Body Fat	41.51	7.87	0.04 (0.71)
Age	51.95	13.84	0.11 (0.31)
PHQ-Depression	4.12	2.97	0.23 (0.02) *
GAD-Anxiety	4.69	3.96	-0.01 (0.91)

The findings from the linear regression including all dependent variables indicated that there were no statistically significant variables correlated to change in BA (see Table 2). Stepwise, step-backwards, and step both analyses were conducted on the linear regression, and in all selection types of the Sit to Stand Test, along with the PHQ-9 test for depression were selected for the regression. Based on the selection of PHAQ-9 and the Sit to-Stand Test in the first regression, a second linear regression was created with just the sit-to-stand test and depression scores (e.g., PHQ-9) as dependent variables, the results are in Table 3. Both dependent values are statically significant in this model (p<0.05).

Table 2

Total Linear Regression
Variable	Estimate	SE	t-value	p-value
Intercept	0.63	0.43	1.46	0.15
Sit to stand	-0.02	0.01	-1.61	0.11
2-minute march	-0.001	0.003	-0.42	0.67
BMI	-0.01	0.01	-0.55	0.58
Body Fat	0.005	0.01	0.50	0.62
GAD-Anxiety	-0.0006	0.02	-0.04	0.97
PHQ-Depression	0.03	0.02	1.72	0.09

Table 3

Final Regression Model.
Variable	Estimate	SE	t-value	p-value
Intercept	0.55	0.16	3.35	0.001
Sit to stand	-0.02	0.009	-2.57	0.01
PHQ-Depression	0.03	0.02	2.20	0.03

The overall goal of this study was to contribute to health and wellness coaching literature by increasing our understanding of the relationship between HWC and body image. Our team examined 1) the relationship between participation in a 3-month HWC program and BA and (2) how the change in BA score was related to physical and mental health at baseline. There were two key findings. First, participation in the HWC program had a positive association with participants’ positive body image. Second, greater improvements in BA were linked to higher levels of baseline depression scores. Taken together, these findings are instrumental to supporting the potential benefits of health wellness coaching.

HWC has been shown to have positive effects on overall wellness in chronically ill populations such as those with heart disease, diabetes, and rheumatoid arthritis (23–25, 27, 47). These studies focused on measures of disease, medication compliance, and overall measures of health. Of note, none of these studies measured BA. If body image is part of wellness, as suggested in studies like those conducted by El Ansari et al (2014) and Becker et al (2019), the results of this study are in line with previous literature (10, 48). However, more concreate work surrounding body image and general wellness should be conducted.

To our knowledge there is no prior published study on the relationship between participation in a HWC program and BA or functional physical health measures such as muscular/cardiovascular endurance (i.e., sit-to-stand and 2-minute march test). Given the current evidence on the positive benefits of physical activity behaviors that result from HWC-focused programs, our findings highlight that adults also accrue benefits that promote healthy reflection in a manner that promotes more positive appreciation. This is important because evidence suggests that individuals who report high levels of body dissatisfaction and lower BA scores also report lower quality of life, higher rates of eating disorders, and higher rates of depression (13, 14).

Several implications can be drawn from the findings of this study. First, the experience of chronic illness may have a negative impact on people’s self-concept, as they experience such things as pain, discomfort, weight gain, changes in appearance, and a loss of control over their own bodies. The social stigma that comes along with illness may lead to other psychological destructive behaviors that impact self-esteem, loss of control over body and emotions, and/or feelings of personal failure (49–51). Nonetheless, as more findings become available on understanding how to promote positive health behaviors through health and wellness coaching, the importance of BA will remain an important area to explore and understand among middle-aged to older women at-risk for or with chronic health illness.

Ultimately, body image can be targeted in an effective way, especially among older populations who struggle to engage in physical activity. The investigation exploring the combined effects of a HWC program on BA and physical health measures in middle-aged to older adults with limited access to health and wellness services is worthy of highlighting. Our findings emphasize that both depression and physical fitness are important factors that contribute to mental health and body image (52, 53). Additionally, because the structure of the program was remote and an extension of an existing, sustained program, the findings of this study indicate that a program like Montana Journey to Wellness is one that can be easily applied in multiple areas such as gyms, schools, or medical facilities. Programs such as this can address the often-undiscussed body image issues of later adulthood, wherever they may be.

The Montana Journey to Wellness program, and the resulting study had multiple strengths starting with the implementation of an existing evidence-based (e.g., over 5 years) HWC program (i.e., Journey to Wellness), into two remote rural areas. To our knowledge, we have not identified other HWC programs that have conducted this collaborative approach to provide access and professional health services in adults at risk for chronic illness. The combined exploration of psychological and physical health measures, highlighting BA as an important factor, is also unique to this body of work within the HWC literature that may lead to other important research areas to explore.

In addition to the strengths of this study, the results must be interpreted within the study limitations. Limitations of this work include a lack of generalizability based on the convenience sampling. This intervention did not have a control group, so we are unable to ascertain how effective HWC is compared to traditional medical interventions or no medical interventions. Additionally, this study only included chronically ill women in a rural setting, and it is not possible to say how generalizable this HWC intervention would be on a different

population.

The overall findings of this study emphasize that Montana Journey to Wellness, a health and wellness coaching program, can have a positive effect on psychological and physical health measures important in the prevention of chronic illness related to cardiovascular disease. The findings also shed light on other associated benefits that can result from adults working with a certified health and wellness coach, specifically in improving BA, and thus contributes to coaching research. The Montana Journey to Wellness was a rural-focused intervention that focused on two geographically isolated communities that have large rates of uninsured, unemployed, and individuals living on the poverty line. The success of this program through marked increases in BA demonstrates the strength of the program and health wellness coaching more broadly.

Abbreviation	Definition
BA	Body Appreciation
BMI	Body Mass Index
GAD-7	General Anxiety Disorder-7
HWC	Health and Wellness Coaching
PHQ-9	Patient Health Questionnaire-9

Ethics approval and consent to participate

The Indiana University Internal Review Board (IRB) provided the study with an exempt ethical approval for the study, in accordance with the Declaration of Helsinki.

Consent for Publication

Not Applicable

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interest

The authors declare that they have no competing interests

Funding

Funding for this study was provided by Health Resources and Services Administration (HRSA) Rural Healthcare Services Outreach Program. Funding provided resources for the program and data collection.

Author’s contributions

KNH. was responsible for conceptualization, formal analysis, and original draft writing.

BR was responsible for project administration.

VMMK was responsible for data curation and funding acquisition.

HZ was responsible for drafting and refining tables.

All authors reviewed and edited the manuscript.

Acknowledgements

We would like to acknowledge The Summit Medical Fitness Center from Logan Medical Health Care Center, Clark Fork Valley Hospital, and the Northern Rockies Medical Center for their collaboration and contribution of health and wellness coaches at each rural site within Montana. We would like to express our gratitude to the professional, certified health and wellness coaches leading within each site, for their passion, collaboration, and implementation of Montana Journey to Wellness, including but not limited to Catherine Lisowski, Michele Maher, Toni Altenburg, Aria Mangan, Sonya French, Holly Nickels, and Greg Vanichkachorn. Lastly, this project would have been possible without the funding award received from the HRSA Rural Health Care Services Outreach Grant, HRSA-18-030.

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No competing interests reported.

The Health Coach Approach: A Secondary Analysis on The Association Between Remote Health Wellness Coaching and Body Appreciation

Status:

Version 1

Abstract

Background

Body Image among Adults

Addressing Body Image

Current Study

Methods

Participants

Measures

Procedure

Statistical Analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1